| * Company Name: |
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| * Policy #: |
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| * Filing State: |
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| * Preparer's Name/Title: |
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| * Email: |
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| * Phone #: |
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| * Date of Loss: |
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| * Employee Name: |
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| * Date Reported To Employer: |
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| * Incident Address (full address): |
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| |
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| * City: |
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| * State: |
* Zip:
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| * Number of Days Expected to Miss: |
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Again,
if all of the required fields above are not filled
in, we cannot process your claim and you will need
to call 508.656.1400.
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| Policy Effective Date: |
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| Account #: |
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| Location Code: |
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| Location Address: |
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| |
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| City: |
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| State: |
Zip:
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| Social Security Number: |
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| Home Phone #: |
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| Home Address: |
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| City: |
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| State: |
Zip:
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| Date of Birth: |
or Age:
Male
Female |
| Marital Status: |
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Spouses Name
(AR, TX, WA, WY): |
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| Regular Occupation: |
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| Regular Department: |
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| Occupation at Time of Injury (NH): |
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Department at Time of Injury
(Al, AR, CA , DE, MD, MI, MN, NM, TX, VT): |
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| Was Employee Injured While on the Job
(OR): |
YES
NO |
| Performing Regular Job Duties? |
YES
NO |
| NCCI Job Class Code: |
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| Employee's Primary Language: |
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| Total # of Dependents (excluding injured
employee): |
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| Is Employee a: |
Partner,
Officer or
Owner of Company ? |
| Hire State: |
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| Employment Status (FT, PT, etc.): |
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| Job End Date (if seasonal or temporary
employee): |
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| Hire Date: |
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| Start Date of Position at Time of Injury: |
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| Name of Group Health Provider (OR): |
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| Hours Worked Per Day: |
Days Per Week:
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| Hourly Rate: |
Weekly Rate:
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| Was Emp. Paid in Full Day of Injury? |
YES
NO |
| Scheduled Days Off: |
S
M
T
W
Th
F
Sa
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| Does Emp. Receive: |
Bonuses
Commissions
Tips
Room or Board
? |
| If yes Amount: |
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| Gross Check 30 Days Prior to Incident
(AZ): |
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| Amount of Employee's Last Check (TX): |
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| # of Hours: |
# of Days:
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| Overtime Hours Worked Per Week: |
Overtime Wage Per Hour:
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| Time of Accident: |
AM
PM |
| Reported to Whom? |
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| Supervisor: |
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| Shift Begin/End Time: |
to
AM
PM |
| Date Emp. Rcvd Claim Form (CA): |
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| County where incident occurred: |
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| Did Incident Occur on Employer's Premises? |
YES
NO |
Description of Accident/Incident (include
what employee was doing, work process, cause injury & body
part):
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| Is This a Questionable Case? |
YES
NO |
| If Yes, Contact Name & Phone #: |
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| Any Signs of Drug or Alcohol Use? |
YES
NO |
| Fatality? |
YES
NO |
| Last Date Worked: |
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| Date of Death: |
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| Time: |
AM
PM |
| First Date Off: |
Was Employee's Salary Continued?
YES
NO |
| Actual or EXPECTED Date of Return to
Work? |
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| Any Previous Claim/Injury? |
YES
NO If Yes, Claim Status (Open/Closed):
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| Body Part Effected: |
Loss Date:
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| Is Safety Equipment Provided? |
YES
NO If Yes, Was it Used?
YES
NO |
| Unsafe Act? |
YES
NO If Yes, Describe:
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| Is There an Active Safety Committee
(NH)? |
YES
NO |
| Was There A Machine Part Involved? |
YES
NO If Yes, Describe:
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| Was the Machine Part Defective? |
YES
NO If Yes, Describe:
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| 3rd Party Responsible for Incident? |
YES
NO If Yes, Name:
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| Address: |
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| |
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| City: |
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| State: |
Zip:
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| Any Witnesses? |
YES
NO |
| Name: |
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| Address: |
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| City: |
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| State: |
Zip:
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| Contact for Additional Information
on Loss: |
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| Phone #: |
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| Address: |
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| City: |
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| State: |
Zip:
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First Aid Given on Site?
(BC, GA, ME, MT, NH, SD) |
YES
NO |
| Medical Treatment Received? |
|