Worker's Compensation


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Worker's Compensation Worksheet Personal Information Name: SSN Spouse's Name: Phone Date of Birth Address Work Phone Employer Employer Address Workers' Comp Insurance Carrier Name Address of the Insurance Carrier Adjuster's Name Lawyer's Name Gross Weekly Salary (Please check the benefits llisted below that you received from your employer while employed). Group Insurance Tips Uniforms Boots Meals Overtime Other Date of Injury Time Place Parts of Body Injured Describe briefly what you were doing and how the accident happened What was your job title How many weeks have you been off work for temporary disability I am currently off work Name of the person you reported the injury to Date reported: Time of day reported Name of any witnesses to the injury Total compensation paid to date Prior injuries or disabilities Prior Worker's Compensation claims: Medical Information Emergency room physician no. 1: (if any) Address: Hospital: Emergency room physician no. 1: (if any) Address: Hospital: Hospitals admitted to because of this injury: (list all) Treating Physicians for this injury: (list all) List all physicians that have treated you in the past 10 years: List all hospitals admitted to in the last 10 years: Family Physician:
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Worker's Compensation Worksheet