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Workers' Comp Claim
POLICY INFORMATION
EMPLOYER’S NAME
(Required)
IF YOU HAVE ALL THE EMPLOYERS INFORMATION
YES
NO
NAME / DBA
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
CONTACT PERSON / SUPERVISOR
(Required)
BUSINESS PHONE NUMBERS
(Required)
FAX NUMBER
EMAIL ADDRESS
EMPLOYEE’S NAME
(Required)
NAME / DBA
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
PHONE NUMBER
(Required)
ALTERNATE CONTACT NUMBER
Email
(Required)
GENDER
MALE
FEMALE
D.O.B.
MM slash DD slash YYYY
DRIVER LICENSE NUMBER
(Required)
SSN
(Required)
LEAVE / DISABILITY DATE
(Required)
MM slash DD slash YYYY
LAST DATE WORKED
(Required)
MM slash DD slash YYYY
HAVE WORKED ANY FULL OR PARTIAL TIME HOURS SINCE YOUR DISABILITY?
YES
NO
STATE DATE
(Required)
MM slash DD slash YYYY
END DATE
(Required)
MM slash DD slash YYYY
LOSS INFORMATION / LEAVE TYPE
TYPE OF LOSS
Work Related Injury
For My own illness or injury
Pregnancy
Family Leave
To Care for a family member who is ill or injured
Family bonding: Newborn, foster child, stepchild, or adopted child
Other
LOSS DESCRIPTION
(Required)
LEAVE / DISABILITY DATE
(Required)
MM slash DD slash YYYY
DATE YOU RECOVERED OR RETURNED TO WORK?
(Required)
MM slash DD slash YYYY
STATE DISABILITY CASE NUMBER
STATE
CASE NUMBER
DOCTOR’S INFORMATION
NAME
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
CONTACT PERSON / SUPERVISOR
PHONE NUMBER
ALTERNATE COTACT NUMBER
EMAIL
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.
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