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Report a Claim
Workers' Compensation Claim Reporting Tips
Please collect the following information. Do not, however, delay reporting your claim if all the information is not available.
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Information about the policy and the insured
- Employer's name
- Address where the accident occurred
- Employer's mailing address
- Description of loss
- Employer's federal identification number (FEIN)
- Date the employer was first notified of accident
- Nature of the employer's business
- Employer's specific products (if applicable)
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Information about the injured employee/claimant
- Employee's ID/social security number
- Employee's name
- Employee's address
- Employee's date of birth
- Employee's home telephone number
- Employee's job title
- Employee's hire date
- Hours/days of the employee's regular work schedule
- Full-time or part-time
- Employee's rate of pay
- Employee's gross wages per week
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Information about the accident
- Date of the accident
- Time of the accident
- Did the employee die?
- Was the employee unable to work at least one full day after the accident?
- Date the employee last worked
- Probable length of disability
- Has the employee returned to work?
- Date the employee returned to work
- Description of the injury
- Description of the accident
- Location of the accident (street address)
- Department and work process involved in the accident
- Names and addresses of any witnesses
- Did the injured employee see a doctor?
- Name, telephone number and address of doctor
- Did the injured employee go to a hospital?
- Name, telephone number and address of hospital
- Length of initial hospitalization
- Injury Form completed by/or an individual reporting this loss?
- Preparer's title
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