WORK COMP CLAIMS

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MINIMUM INFORMATION REQUIRED TO SUBMIT A WORK RELATED INJURY OR ILLNESS CLAIM

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EMPLOYEE INFORMATION NEEDED:

FULL NAME
ADDRESS
SSN# (PROVIDE OVER THE PHONE)
DOB
MARITAL STATUS
PHONE
DATE OF HIRE
GENDER
DEPARTMENT REGULARLY WORKED
EMPLOYMENT STATUS:

  FULL

  PART

  SEASONAL

  VOLUNTEER

WAGE PERIOD - HOURLY or DAILY
PAYROLL:

  WEEKLY

  BI-WEEKLY

  MONTHLY

NUMBER OF DAYS WORKED PER WEEK
OCCUPATION DESCRIPTION
SALARY CONTINUED IN LIEU OF COMPENSATION?
FULL WAGES PAID FOR DATE OF INJURY?

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LOSS INFO NEEDED: 

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REPORT NUMBER IF APPLICABLE 
DATE OF INJURY
DATE EMPLOYER NOTIFIED OF INJURY
TIME EMPLOYEE BEGAN WORK ON INJURY DATE 
BODY PART AFFECTED
NATURE OF INJURY
CAUSE OF INJURY
DESCRIBE INJURY OR ILLNESS OCCURRED INCLUDING WHAT EMPLOYEE WAS DOING BEFORE & HOW HARMED THE EMPLOYEE?
DATE LAST DAY WORKED
DATE DISABILITY BEGAN
DID INJURY OR ILLNESS OCCURR ON EMPLOYER'S PREMISES?
ADDRESS WHERE INJURY OCCURRED 
PHYSICIAN NAME AND ADDRESS
HOSPITAL NAME AND ADDRESS
INITIAL TREATMENT:

  NO MEDICAL

  MINOR BY EMPLOYER

  MINOR BY CLINIC OR HOSPITAL

  HOSPITALIZED > 24HRS/EMERGENCY CARE

  FUTURE MAJOR MEDICAL & LOST TIME ANTICIPATED
 

PREPARER NAME TITLE AND PHONE NUMBER
 

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DOWNLOAD THE TENNESSEE C20 FORM 

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DOWNLOAD THE MISSISSIPPI  REPORT FORM

 

 

 

SEND INFORMATION AND OR FORM TO claim@4wayinsurance.com OR FAX to 901-386-2453