Workmans Comp Claims

Insured's Company Name:
        Contact person at Company:
        Best phone # to reach contact:
Insurance Company:
Policy #:
Date of occurrence: Time of occurrence:


Injured Employee's (EE) Info:

Name: Phone:


Date of hire: State hired in:

Rate of pay: Full Time or Part Time:

Job title:
Marital Status: Dependents:

Health Insurance:
What time did EE start work that day:
Where did incident occur:
        Jobsite, shop, which dept, etc.
What happened:
Type of Injury:
Any safety precautions used:
        If yes, describe:
When was Insured notified:
Where was EE treated:
        Released or Admitted:
Is EE being paid for the remainder of the day:


Name: Phone Number:

Please fill out as many details as possible, we need ALL of this info to submit claim.