Fill and Sign the Workers Compensation Questionnaire Form

WORKERS’ COMPENSATION CLAIM QUESTIONNAIRE I. PERSONAL INFORMATION NAME (First, Middle, Last) NAME CALLED MAILING ADDRESS - STREET ADDRESS (If Different from mailing address) CITY STATE ZIP HOME PHONE WORK PHONE OTHER PHONE AGE DATE OF BIRTH SOCIAL SECURITY NO. MARITAL STATUS: Married/Single/Divorced/Widowed/Separated Date of Marriage/Divorce/Widowed: SPOUSE’S NAME CHILDREN’S NAMES & AGES SPOUSE GROUP INS. OTHER HEALTH INS. COVERAGE CRIMINAL RECORD REGISTERED TO VOTE? II. EMPLOYMENT INFORMATION: EMPLOYER NAME EMPLOYER PHONE NUMBER EMPLOYER’S ADDRESS (Street, City, State, Zip) SUPERVISOR DATE EMPLOYED JOB TITLE RATE OF PAY AVG. HRS./DAY SHIFT SICK PAY TEMPORARY TOTAL PAID? Y/N DATES AMOUNT $ PART-TIME EMPLOYMENT? Y/N EMPLOYER ADDRESS OF PART-TIME EMPLOYER RATE OF PAY LOST WAGES? Y/N DATES MISSED III. INSURANCE CARRIER INFORMATION: WORKERS’ COMP INSURANCE CARRIER CARRIER’S ADDRESS (Street or P.O.>Box, City, State, Zip) ADJUSTER NAME &PHONE NUMBER INSURED CLAIM NUMBER POLICY NUMBER IV. THIRD PARTY DEFENDANT: ADVERSE PARTY’S NAME (First, Middle, Last) (Name of any person who caused injury) AP’S ADDRESS (Street or P.O. Box, City, State, Zip) V. THIRD PARTY INSURANCE INFORMATION: INSURANCE COMPANY INSURANCE COMPANY ADDRESS ADJUSTER’S NAME & PHONE NUMBER INSURED VI. ACCIDENT INFORMATION: DATE OF INJURY TIME LOCATION PART(S) OF BODY INJURED DESCRIBE HOW ACCIDENT OCCUURED ACCIDENT REPORTED? Y/N REPORTED TO TITLE/POSITION DATE REPORTED WITNESSES (NAMES AND PHONE NUMBERS) VII. MEDICAL TREATMENT: NAME & ADDRESS OF TREATER NAME & ADDRESS OF TREATER NAME & ADDRESS OF TREATER NAME & ADDRESS OF TREATER VIII. CLAIM HISTORY: IX. PRIOR MEDICAL / CLAIM HISTORY: