Workers Comp Claim Application

Workers Compensation Claim Application

Claim Identifiers

Claim Reference Number:    Date Filed:

Insured / Claimant Information

Date of Birth:    Phone:    Email:

Employer / Work Site

Supervisor Name:    Supervisor Phone:

Policy / Coverage Details

Policy Number:    Policy Type:

Coverage Amount:    Deductible:    Premium:

Policy Period From:    To:

Coverage Types (select all that apply)

Medical benefits
Temporary or permanent disability indemnity
Vocational rehabilitation
Death benefits
Employer's liability

Injury / Claim Details

Date of Injury or Occupational Illness:    Time of Injury:

Witness(es):    Reported to Employer: Yes No

Claim Type: New    Recurrence    Aggravation of prior condition

Medical Treatment

Date of First Treatment:    Hospitalized Overnight: Yes No

Documentation Checklist (attach copies where available)

Medical reports and records
Employer incident/accident report
Witness statements
Photographs of incident or injury
Payroll / wage records
Other supporting documentation attached

Beneficiary / Third-Party Information

Beneficiary Name:    Relationship:    Allocation %:

Exclusions / Limitations (acknowledge)

The claimant acknowledges that coverage is subject to policy terms, exclusions for willful misconduct, intoxication, or intentionally self-inflicted injury, and that eligibility for benefits will be determined under applicable law and policy provisions. By signing this application the claimant requests claim investigation and does not alter or expand policy obligations beyond the insurer's written policy.

Claim Declaration and Authorization

I certify under penalty of perjury that the information provided in this application is true, complete and correct to the best of my knowledge. I authorize any treating medical provider, employer, or other entity having relevant records to release pertinent medical, employment and wage records to the insurer, its representatives, and to governmental agencies where required by law. I acknowledge that false statements or omissions may subject me to criminal prosecution and civil penalties and may result in denial of benefits.

I understand that submission of this form initiates investigation of the claim. I agree to cooperate with reasonable requests for additional information, examinations by approved medical professionals, and to provide documentation necessary to establish entitlement to benefits. I further acknowledge possible subrogation rights of the insurer against third parties where applicable.

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