Insurance WC Statement

INSURANCE WC STATEMENT

Insurer Name:    Policy No.:    Statement Date:

Insured / Applicant Information

Contact Person:    Phone:    Email:

Insured Federal Tax ID / EIN:    Date of Birth (if individual proprietor):

Policy Details

Workers' Compensation coverage Employers' Liability coverage Other (specify below)

Policy Period From:    To:

Annual Premium:    Deductible:    Limits / Employers' Liability:

Coverage Summary

Select coverages included in this policy (check all that apply):

Medical benefits for work-related injuries and illnesses Wage replacement / temporary total disability benefits Permanent partial disability benefits Vocational rehabilitation / retraining Death and survivor benefits Employers' liability coverage (limits shown above)

Exclusions and Endorsements

The policy issued excludes or modifies coverage as set forth in attached endorsements. Indicate known endorsements or common exclusions that apply:

Non-occupational disease exclusion Intentional act / willful misconduct exclusion Independent contractor exclusion (where applicable) Prior acts or retroactive date limitations Other endorsements / specific provisions:

Claim / Event Information (If applicable)

Job Title:    Date of Injury/Exposure:    Time of Injury:

Immediate Medical Treatment Provided:    Estimated Medical Cost to Date:

Did injury result in lost time from work? Yes No    If yes, estimated number of work days lost:

Documentation Checklist

Please indicate which documents accompany this statement:

Medical records and physician reports Hospital and billing statements Employer's incident report / first report of injury Witness statements Photographs of incident site / injury Police or accident investigation report Other documentation (describe):

Beneficiary / Death Benefit Designation (If applicable)

Provide beneficiary information for death benefits under the Workers' Compensation policy, if applicable. Percentages must total 100%.

Relationship:    Percentage:

Relationship:    Percentage:

Declaration, Authorization and Fraud Notice

I certify under penalty of law that the information contained in this Insurance WC Statement is true, complete and accurate to the best of my knowledge. I understand that material misrepresentation, omission or falsification of information in this statement may constitute insurance fraud and may subject me to civil or criminal penalties under applicable law.

I authorize the insurer and its authorized representatives to obtain, verify and disclose any information necessary to investigate, evaluate or administer any claim or coverage identified by this statement, including but not limited to medical records, employment records and wage information. I also authorize providers, employers, and other entities to release such information to the insurer.

This statement and any attachments constitute a statement of facts relied upon by the insurer. Coverage determinations are made in accordance with the policy terms and governing workers' compensation statutes and regulations.

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