Optional

NOTE: A copy of this file will be provided to you in a password protected PDF, please provide a password to obtain access.

Employer

Employer (Address)
Employer's Location Address (If Different)

Carrier (Claims admin)

Check if appropriate

Employee

Name
Employee Address
Date of Birth
Date Hired
Claimant may need an interpreter?
Sex
Marital Status

Wage

Rate per
Full Pay for Date of Injury?
Did Salary Continue?

Occurence

Time Employee Began Work
:  
Date of Injury/Illness
Time of Occurrence
:  
Last Work Date
Date Employer Notified
Date Disability Began
Contact Name
Did Injury/Illness Exposure Occur on Employer’s Premises?
Date Returned to Work
If Fatal, Date of Death
Were Safeguards or Safety Equipment Provided?
Were they used?
Physician/health care provider address
Hospital Address
Initial Treatment

Other

Date Administrator Notified
Date Prepared
Name*
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