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Injury information for workers' compensation claims
While we don’t need this information to initiate a claim, we will ask you for this
information at some point so we can help manage the claim:
- Employee’s name, address, phone number and job description
- Employee’s Social Security number
- Employer’s name and address
- Employee’s date of birth, marital status and number of dependents
- Employee’s length of employment
- Employee’s gross weekly salary and weekly work hours
- Names of witnesses or first person to arrive at the scene of the accident/injury
- Date, time and place of accident
- Complete description of the accident
- Complete description of the injury
- Employee’s medical status and physician/hospital name
- When the employee returns to work
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