Workers' Compensation Claims

Workers' Compensation Claim Reporting Guide

Please do not delay in reporting the claim even if you do not have all the necessary information.

Account Information

  • Caller's phone number and extension
  • Caller's name and title
  • Benefit state
  • Employer's name and address
  • Employer's mailing address (if different from above)
  • Parent company/Insured's name
  • Location code
  • Nature of business
  • Policy form and number

Employee Information

  • Name
  • Male or female
  • Social Security number
  • Employee's mailing address
  • Employee's home address (if different from above)
  • Marital status
  • Employment status (full time or part time)
  • Number of dependents
  • Class code
  • Date of birth
  • Wage period
  • Home phone number

Accident Information

  • Date of injury
  • Time of injury
  • Date claim reported to employer
  • Was the accident on employer's premises?
  • Accident location
  • Did employee lose any time from work?
  • Is employee back at work? (If yes, date returned)
  • Date employee last worked
  • Was employee paid for last date worked?
  • Date employee last paid
  • Date disability began and ended
  • Is/was employee's salary continued?
  • Was employee's injury related to a company-sponsored event?
  • Was accident fatal? (if yes, date of death)
  • Description of accident
    Cause of accident (e.g., slip/fall, lifting, chemical)
  • If motor vehicle accident, driver's license number and state where issued
  • Contributing factors
  • Equipment, material or substance involved
  • Names, addresses and phone numbers of other parties involved
  • Were safeguards provided (if yes, describe)
  • Were safeguards in use at time of accident?
  • Names, addresses and phone numbers of witnesses

Injury Information

  • Part of body injured (e.g., head, neck, arm, leg)
  • Nature of injury (e.g., fracture, sprain, laceration)
  • Previous related condition
  • Pre-existing medical condition(s)
  • Cumulative injury? (if yes, length of exposure)
  • Nature of duties
  • Length of time doing activity
  • First aid (who, treatment and date of 1st treatment)
  • Hospital/clinic (name, address, treatment, length of stay, date of 1st treatment)
  • Physician (name, address, phone number, treatment, specialty, date of 1st treatment)

Employee Job Information

  • Occupation when injured
  • Regular occupation
  • Date of hire
  • Schedule (regular work hours, hours per day, days per week)
  • Wage (hourly, annual, average weekly, overtime/per, additional benefits/per)
  • Supervisors name, phone number and scheduled work hours

Our Customers Say

Jacquelynne Maloney at the Tonry agency has helped us immeasurably navigating the bonding process.  She took the time to get to know us and develop a complete picture of our company, our goals and objectives, our capabilities, our needs and the history of our company.  Her knowledge of the market allowed her early on to recognize what program would work for our company.  Other bonding agencies simply asked for a copy of our financial statement, balance sheet and work on hand.  They appeared to have no interested in whether we were making cupcakes or nuclear missiles.  Jacquelynne took the time to get to know us personally.  To her we were more than just our financial statement.

President

Richardson Electrical Company, Inc.

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