Work Injury Application

· Your Information ·

Questions in bold are required.

First Name: Last Name: Date of Birth: Mailing Address: City: State: Zip: Phone Number:

Gender:

Male Female Insurance Carrier: Carrier Address: City: State: Carrier Zip:

Did you file an employee's claim for compensation form (C-3) with the Workers Compensation Board?

Yes No If yes, what date did you file the C-3 form? WCB Case Number? (If you know it)

Have you attended a workers compensation hearing?

Yes No

· Employer Information · Employer when injury occurred: Work Phone: Work Address: City: State: Zip: Date Hired: Supervisor's Name: Job Title: Job Activities:

What was your job?

Full Time Part Time Seasonal Volunteer Other What was your gross pay (before taxes) per pay period? How often were you paid?

Did you receive Lodging or tips in addition to pay?

Yes No If yes, briefly describe:

Other Employment List any other employer(s) names/addresses at time of injury: Work Address: City: State: Zip:

Did you lose time from work at other employment(s) as a result of your injury/illness?

Yes No

Injury or Illness Date of your injury or onset of illness? Time of injury (specify am or pm)? Where did injury or illness occur? (For example 10 Albany street, front door)

Was this your usual work location?

Yes No If no, why were you at this location? (brief) What were you doing when you were injured or became ill? (ex. Loading truck) How did the injury/illness happen? (tripped on tool and fell on floor) Nature of your injury/illness and body parts affected? (Ex. Separated shoulder and black eye)

Was an object (ex. Tractor, saw, chemical) involved in your injury/illness?

Yes No If yes, what?

Was the injury the result of operation of a motor vehicle?

No My Vehicle Employers Vehicle Other Vehicle License plate number? (if known) If it was your vehicle, give name and address of your motor vehicle insurance carrier

Have you given your employer or supervisor notice of injury/illness?

Yes No If yes, who did you notify and how? Orally? In writing? Date notice given:

Did anyone see your injury occur?

Yes No Unsure If yes, who? (list names)

Return to Work

Did your injury/illness prevent you from working?

Yes No

If yes, have you returned to work since?

Yes No If yes, on what date(day/month/year) and in what capacity? (Regular duty/limited duty)

If you have returned to work who is your current employer?

Same New Self What is your gross pay(before taxes) per pay period? How often are you paid? If you have not returned to work, when was your last day of work? Does your employer pay your full wages? If no, is your insurance carrier sending you payments? If so how much?

Medical Treatment

Did you receive medical treatment for your injury or illness?

Yes No

If yes were you treated on site?

Yes No Date of your first treatment?

Did you receive medical treatment for your injury or illness?

Emergency Room Physician's Office Clinic/Hospital/Urgent Care Hospital Stay over 24 Hours Name and Address where you received your first treatment: Address: City: State: Zip:

Are you still being treated for this injury/illness?

Yes No Date of most recent treatment: Name and address of the doctor(s) treating you?

Have you had another injury to the same body part or a similar illness?

Yes No

If yes, were you treated by a doctor?

Yes No If yes, please provide name and address of doctor(s)

Was the previous injury/illness work related?

Yes No

If yes, were you working for the same employer that you are currently working for?

Yes No