Your Information

Your Name:	Date:
Email Address:
Claimant/Employee Information
Name:	D.O.B.:
SSN:	Sex: Male Female
Home Address:
City: State Zip:
Phone #:
Job Title:	Date Hired:
Related to Owner: Yes No	Relationship:

Continue to Step 2 >>

Employer Information:
Employer:	Nature of Business:
Mailing Address:
Physical Address (if different):
Employer Phone #:	WC Policy #:

Continue to Step 3 >>

Payroll Information:

Average Weekly Wage:

Did the employee receive lodging or tips in addition to pay? Yes   No
If yes, describe:

Employees Job Was (check one): Full Time Part Time Seasonal Volunteer Other
If other, please describe:

Work Week (days worked): M T W TH F SA SU

Was the employee paid for a full day on the day of the injury/illness? Yes   No

Last date worked:

Last date paid:     In Full? Yes   No

Did you continue to pay the employee after the injury/illness (e.g. sick leave, vacation, disability, regular salary)? Yes   No     If Yes, please describe:

If Yes, is reimbursement requested? Yes   No

Continue to Step 4 >>

ACCIDENT INFORMATION:
Date of Accident:    Time of Accident: AM PM
Time of day employee began to work on date of injury: AM PM
Has the employee given you notice of injury/illness? Yes No
If Yes, Name & Title of person whom accident was reported: Oral Written
His/Her phone #:     Date Notice Provided:

Address where accident occurred: Assured address? Yes No
If No, please give address where accident occurred:
Was this location where the employee normally worked? Yes No
If No, Why was employee there?

Employee's Supervisor:
Did Supervisor see injury happen? Yes No Unknown
Did anyone else see the injury happen? Yes No Unknown
If yes, name of witness:
What was employee doing when injured?
What body part was affected?
Was an object (e.g. forklift, hammer, acid?) involved in injury/illness? Yes No
If Yes, What was it?
Was the injury the result of the use or operation of a licensed motor vehicle? Yes No
If Yes, Employer's vehicle Employee's vehicle Other vehicle
License plate number (if known)
Auto Insurance information:


Continue to Step 5 >>

Accident Information (continued)
Did the injury/illness result in the employee's death? Yes No
If Yes, what was the date of death?
Are you disputing the accident? If so, why?


If Non-Work Related or You Are Disputing this claim then NYS Disability Insurance Information is required
NYS DB Company:
Address:
City, State, Zip:
Policy#:

Have you given the employee a Claimant Information Packet? yes no
If yes, when was it given?

Continue to Step 6 >>

Medical Treatment Information:
Date of Employee's first medical treatment: None received Unknown
Where did the employee receive first medical treatment for this injury/illness? Onsite Doctor's office Emergency Room Clinic/Hospital/Urgent Care Hospital stay over 24 hours Unknown
Who treated the employee and where?
Doctor Name:     Hospital/Clinic Name (if applicable):
Address:      Telephone:
Is the employee still being treated for this injury/illness? Yes No Unknown
If Yes, name and address of treating doctor(s):

To your knowledge, did the employee have another work-related injury to the same body part or a similar illness while working for you? Yes No

Continue to Step 7 >>

Return to Work Information:
Did the employee stop work because of his/her injury/illness? Yes No
If Yes, on what date?
Light duty available? Yes No
Is claimant/employee back to work? Yes No    Date of return to work:
Full Pay? Yes No    If No, average gross earnings?

Comments:

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