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Worker Compensation Claim Form Template

Simplify the Claims Process for Your Employees

Filing a worker compensation claim can be overwhelming for both employees and employers. This template is designed to help you efficiently gather necessary information and expedite the claims process. You can easily reduce errors, provide clear guidance for your employees, improve communication with insurance providers, and ensure compliance with regulations. Get started and customize your own claim form today to facilitate a smoother claims experience.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Home mailing address
Email address
Mobile phone
Job title or position
Employer or business name
Worksite address
Supervisor name
Date of injury
Time of injury (e.g., HH:MM)
Incident location (area, building, or site)
Was the incident reported to a supervisor?
Yes
No
Describe what happened
Main cause of injury
Slip, trip, or fall
Overexertion or repetitive motion
Struck by object
Caught in or between
Exposure to harmful substance or environment
Motor vehicle incident
Workplace violence
Unknown
Other
Please Specify:
Was this during your normal work duties?
Yes
No
Nature of injury
Please Specify:
Body part(s) affected
Please Specify:
Date of first treatment
Treating provider or facility
Current symptoms or treatment plan
Did you receive medical treatment?
Yes
No
Did you miss work because of this injury?
Yes
No
First full day missed (if any)
Current work status
Full duty
Modified or light duty
Off work
Unknown
Witness names and contact information (if any)
Do you have primary health insurance?
Employer-sponsored plan
Private plan
Government program
None
Prefer not to say
If yes, please describe the pre-existing condition
Pre-existing condition affecting the injured area?
Yes
No
I certify the information provided is true and complete to the best of my knowledge.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Signer full name (type to sign)
Signature date
I authorize the release of relevant medical and employment information to process this claim.
Yes
No
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Paper art illustration depicting a worker compensation claim form for a FormCreatorAI article

When to use this form

Use this form when an employee is hurt or becomes ill because of work. It helps you document the incident fast, notify HR and your insurer, and start wage replacement and medical care. Typical cases include a slip in the warehouse, back strain from lifting, a needlestick in a clinic, or carpal tunnel after repetitive tasks. Supervisors and safety teams benefit from clear timelines and witness details, while employees get a trackable record for benefits. If your issue is about a defective product instead, use the Warranty claim form. For plan changes unrelated to an injury, submit the Health insurance cancellation form.

Must Ask Worker Compensation Claim Questions

  1. When did the injury or illness occur, and where were you working at the time?

    This captures date, time, and location to verify eligibility and align with schedules or video logs. Clear facts reduce disputes and speed insurer review.

  2. What task were you performing, and what equipment or materials were involved?

    Job context shows if the event arose from your duties and reveals hazards to fix. Listing tools or chemicals guides follow-up, like checking protective gear or safety data sheets.

  3. What injuries or symptoms do you have, and which body parts are affected?

    Specifics support triage and correct coding, which affects treatment and wage benefits. Detail avoids rework and helps your provider plan care.

  4. Did you receive medical treatment? If yes, list the provider, facility, diagnostics, and any prescriptions.

    Treatment details confirm seriousness and build the record your insurer needs. For medication reimbursements outside this process, you can use the Medicare prescription claim form.

  5. Were there witnesses, prior similar injuries, or safety controls in place (training, PPE, guards)?

    These facts help determine cause, fault, and preventative steps. They also guide return-to-work plans and potential accommodations.

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