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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:
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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
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Employee’s length of employment
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Employee’s gross weekly salary and weekly work hours
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Names of witnesses or first person to arrive at the scene of the
accident/injury
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Date, time and place of accident
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Complete description of the accident
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Complete description of the injury
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Employee’s medical status and physician/hospital name
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When the employee returns to work
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