Occupational Health Insurance Claim
Claimant Information
Full Name: [Your Name]
Employee ID: 123456
Date of Birth: January 15, 2025
Address: 456 Future Lane, Metropolis, NY 10001
Phone Number: (555) 987-6543
Email: [Your Email]
Employer Information
Company Name: [Your Company Name]
Company Address: [Your Company Address]
Company Phone Number: [Your Company Number]
Company Phone Email: [Your Company Email]
Supervisor Name: Jane Smith
Supervisor Email: jane.smith@futuretech.com
Incident Details
Date of Incident: March 3, 2051
Time of Incident: 2:30 PM
Location of Incident: Main Production Floor, Section B
Description of Incident: While operating the automated assembly line, a malfunction caused a robotic arm to strike the claimant on the right shoulder, resulting in a dislocation.
Medical Treatment Information
Initial Medical Treatment Date: March 3, 2051
Treating Physician Name: Dr. Emily Clark
Hospital/Clinic Name: Metropolis General Hospital
Hospital/Clinic Address: 123 Health Blvd, Metropolis, NY 10001
Phone Number: (555) 654-3210
Description of Treatment: Emergency reduction of shoulder dislocation, X-rays, and MRI to assess damage. Prescribed pain medication and scheduled follow-up physical therapy.
Claim Information
Claim Number: 789012345
Type of Injury: Shoulder Dislocation
Body Part Affected: Right Shoulder
Estimated Time Off Work: 4 weeks
Expected Return to Work Date: April 3, 2051
Additional Notes: The claimant is to undergo physical therapy twice a week for 4 weeks. Regular check-ups to monitor recovery progress.
Signature and Acknowledgement
I hereby certify that the above information is true and accurate to the best of my knowledge. I understand that providing false information can result in denial of my claim and potential legal action.
[Supervisor's Name]
[Your Name]
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