Workman's Comp Claim
EMPLOYEE'S CLAIM
Worker's Compensation Commission
 
PERSONAL INFORMATION
 
Claimant First Name
 Claimant Middle Initial
 Claimant Last Name
Mailing Address
 Phone Number
City
County
 State
Zip Code
Social Security Number
 Sex
 Date of Birth
 Marital Status
 
Gross Wages per Week
Paid Full Wages For Day?
 
What is Your Regular Work?
What Was Your Work When Injured?
 
EMPLOYER INFORMATION
 
Full and Correct business name of your employer
Complete address
 Employer Phone Number
City
 State
Zip Code
Nature of Employer's Business
 Location where accident occurred
 Notice of Injury Given?
Whom did you notify of the accident?
First day not worked
 Occupational Disease?
Date of Accident/occupational disease disablement
 Time
 
Describe how accidental injury occurred
OR
Describe how occupational disease occurred
 
 
CLAIM INFORMATION
 
What member off your body was injured?
Amputation required?
Employer requested to provide medical care?
Medical care provided
Date returned to work
 
Attending physician name
 Address
 Apt. / suite
City
 State
Zip code
 
If you were in a hospital, hospital name?
 Address
 Apt. / suite
City
 State
Zip code
 
If you were represented by an attorney, attorney name?
 Address
 Apt. / suite
City
 State
Zip code
 Attorney's phone number
 
Is this the only worker's compensation claim you have filed for this accident or occupational disease
 If no give claim #
If health insurance used, give name of Insurance Company