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]