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