Fill and Sign the Compensation Claims Form

Checklists - Worker's Compensation Claims Drafting an application for adjudication of a workers' compensation claim by the compensation board or commission or a hearing officer:  Full name and complete address of employee and employer.  Date, time and place of injury.  Occupation and actual work being done by employee at time of injury.  Statement that employee was in the employ of named employer and accident arose out of and in the course of such employment.  Brief description of accidental occurrence.  Nature and extent of injury.  Work classification bringing employer within those to whom compensation act applies.  Name and address of insurer, and allegation that employer was duly insured for compensation liability, or was self-insured.  Due notice to employer of accident and injury.  Denial of any or adequate payment of benefits.  Weekly wage (or average weekly wage) of employee at time of injury.  Benefits requested. Drafting a claim for compensation benefits to a court:  Name and address of employer and employee.  Date, time and place of accidental injury.  Occupation, and particular activity of employee at time of injury.  That injury occurred in the course of and arose out of employment for employer.  Brief description of cause of accident.  Nature and extent of injury.  That employer and employee were subject to the workers' compensation laws of the state.  Nature and extent of employee's disability.  Due and proper notice to employer of happening of accidental injury.  Weekly wage or average weekly wage of employee at time of injury.  Request for full benefits.