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Workers Comp Claim Form |
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Name: |
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Home Address: |
City:
State:
Zip: |
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Telephone: |
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Occupation: |
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Date of Birth: |
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Sex: |
Male
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Female |
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Employee Information |
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Social Security Number |
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Date of Accident (Month-Day-Year) |
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Time of Accident |
AM
PM |
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EMPLOYEE'S DESCRIPTION OF ACCIDENT (Include Cause of
Injury) |
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INJURY/ILLNESS THAT OCCURRED |
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| PART
OF BODY AFFECTED |
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EMPLOYER INFORMATION |
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COMPANY NAME: |
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D. B. A.: |
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Street: |
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City: |
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State: |
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Zip: |
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TELEPHONE |
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FEDERAL I.D. NUMBER (FEIN) |
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| DATE
FIRST REPORTED (Month/Day/Year) |
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NATURE OF BUSINESS |
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| POLICY/MEMBER
NUMBER |
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DATE EMPLOYED
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PAID FOR DATE OF INJURY
YES
NO |
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EMPLOYER'S LOCATION ADDRESS (If different) |
Street:
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City:
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State:
Zip: |
LOCATION #
(If applicable) |
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LAST DATE EMPLOYEE WORKED
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RETURNED TO WORK
YES
NO
IF YES, GIVE DATE
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WILL YOU CONTINUE TO PAY WAGES INSTEAD OF
WORKERS' COMP?
YES |
LAST DAY WAGES WILL BE PAID
INSTEAD OF WORKERS' COMP
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PLACE OF ACCIDENT |
Street:
City: |
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State:
Zip:
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COUNTY OF ACCIDENT |
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DATE OF DEATH (If applicable)
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RATE OF PAY PER
HR
WK
DAY
MO |
AGREE WITH DESCRIPTION OF ACCIDENT?
YES
NO |
Number of hours per day
Number of hours per week
Number of days per week
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Name Address Phone of physician or hospital |
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Authorized by employer |
Yes
No |
Any person who,
knowingly and with intent to injure, defraud, or deceive
any employer or employee, insurance company, or
self-insured program, files a statement of claim
containing any false or misleading information commits
insurance fraud, punishable as provided in s. 817.234.
Section 440.105(7), F.S. I have reviewed, understand and
acknowledge the above statement. |
