WORKERS' COMPENSATION CLAIM
Employee Information | Employment Information |
Full Name: Jane Salers Employee ID: EI-12345 Contact Info: 222-555-7777 | Job Title: Warehouse Supervisor Supervisor's Name: Jane Doe Date of Hire: 06/10/2050 |
Injury/Illness Details | Date: 09/15/2053 | Time: 10:30 AM | Location: Warehouse A |
Description of Incident/Illness: While lifting a heavy box, I felt a sudden sharp pain in my lower back. I immediately reported it to my supervisor, Jane Doe. |
Medical Treatment | Name of Treating Physician: Dr. Sarah Jones | Clinic/Hospital Name: Anytown Medical Center |
Address: 456 Oak Avenue, Anytown, USA | Contact Info: 222-555-7777 | Date of First Treatment: 09/16/2053 | Diagnosis: Strained Lower Back Muscles |
Witness Information | Name: Mary B. Anderson | Contact Information: 222-555-7777 |
Employee Statement | Supervisor's Statement |
I, Jane Salers, hereby request Workers' Compensation benefits due to the injury sustained at work as described above. I certify that the information provided on this form is accurate and complete to the best of my knowledge. Employee Signature:_____________________ Date: 09/21/2053 | I, Jane Doe, confirm that the incident as described by Jane Salers occurred as reported. I have reviewed this claim form and provided the necessary information. Supervisor's Signature:_____________________ Date: 09/21/2053 |
*** HR Department Use Only *** |
Claim Number: WC 2053-12345 | Date Received: 09/21/2053 | Reviewed by: [Your Name] |
Status: [ ] Approved [ ] Denied [ ] Under Review
Please submit this completed form to the HR department for processing within 24 hours of the incident. For any questions or assistance, contact the HR department at [222-555-7777] or email us at [Your Email]. You may also visit our company website at [Your Company Website].
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