WORK COMP CLAIMS
MINIMUM INFORMATION REQUIRED TO SUBMIT A WORK RELATED INJURY OR ILLNESS CLAIM
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?
LOSS INFO NEEDED:
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
DOWNLOAD THE TENNESSEE C20 FORM
DOWNLOAD THE MISSISSIPPI REPORT FORM
SEND INFORMATION AND OR FORM TO claim@4wayinsurance.com OR FAX to 901-386-2453
TENNESSEE C-20 FORM


