Workers Compensation Insurance Claim
Employee Information
Name: [Your Name]
Employee ID: 546512
Department: Manufacturing
Position: Machine Operator
Incident Details
Date of Incident: October 15, 2050
Time of Incident: 10:30 AM
Location: Factory Floor, Section B
Nature of Injury/Illness
Type of Injury: Fractured Right Arm
Symptoms: Severe Pain, Swelling, Limited Mobility
Immediate Treatment: First Aid Administered on Site
Medical Expenses
Service | Cost ($) |
|---|
Emergency Room Visit | 600 |
X-Ray Imaging | 200 |
Orthopedic Consultation | 300 |
Medication | 50 |
Follow-up Visits | 150 |
Lost Wages
Date Range: October 16, 2050 - November 15, 2050
Total Days Absent: 30
Daily Wage Rate ($): 100
Total Lost Wages ($): 3000
Other Related Costs
Transportation Costs: $100
Physical Therapy Sessions: $500
Home Care Assistance: $250
Total Financial Compensation Sought
Category | Total Amount ($) |
|---|
Medical Expenses | 1300 |
Lost Wages | 3000 |
Other Related Costs | 850 |
Grand Total | 5150 |
|---|
Employee's Declaration
I, [Your Name], hereby affirm that the information provided in this insurance claim is accurate and complete to the best of my knowledge. I acknowledge that any misrepresentation or false information may result in the denial of my claim or other legal consequences.
[YOUR NAME]
[DATE SIGNED]
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