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