Form Wc9552A PDF Details

In the world of workplace safety and compensation, few documents are as pivotal as the WC9552A form. This form serves as the primary vehicle for reporting job injuries or illnesses by workers in the self-insured employers' ecosystem. It meticulously captures essential details about the worker and the incident—spanning from the nature and body part affected by the injury or illness, the circumstances leading to it, right through to the specifics of the injury date, time, and the environment in which it occurred. Additionally, it places a significant emphasis on the worker's decision to claim or not to claim workers' compensation benefits, drawing a fine line between mere reporting and the formal initiation of a compensation claim. The form also facilitates the legal requirement for employers to notify their workers’ compensation insurance company post-haste upon becoming aware of a claim. Moreover, it acknowledges the complex interplay of federal regulations, such as HIPAA, underscoring the legal delicacies involved in handling workers' personal and medical information. Ultimately, the form acts as a gateway, not just for the initiation of claims but for the preservation of rights, both for the employer and the injured or ill worker, underpinning the broader framework of workplace safety, health regulation, and workers’ compensation insurance.

QuestionAnswer
Form NameForm Wc9552A
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesWolters, blank 801 form, Birthdate, Oregon

Form Preview Example

Insert self-insured employer and insurer name, address, phone number, and service company, if any.

Report of Job Injury or Illness

Workers’ compensation claim

Worker

To make a claim for a work-related injury or illness, fill out the worker portion of this form and give it to your employer. If you do not intend to file a workers’ compensation claim with the insurance company, do not sign the signature line. Your employer will give you a copy.

Date of

 

Date you

 

Time you began work

a.m.

Regularly scheduled

DEPT USE:

injury or illness:

 

left work:

 

on day of injury:

p.m.

days off:

Emp

Time of injury

a.m.

Time you

a.m.

Check here if you have more than one

 

 

 

M T W T F S S

Ins

or illness:

p.m.

left work:

p.m.

job:

 

 

 

 

 

 

 

 

 

 

What is your illness or injury? What part of the body? Which side? (Example: Sprained right foot)

 

Left

Right

Occ

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nat

 

 

 

 

 

 

 

 

 

What caused it? What were you doing? Include vehicle, machinery, or tool used. (Example: Fell 10 feet when climbing an

Part

 

extension ladder carrying a 40-pound box of roofing materials)

 

 

 

 

Ev

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Src

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2src

 

 

 

 

 

 

 

 

 

Information ABOVE this line; date of death, if death occurred; and Oregon OSHA case log number must be released to an authorized worker representative upon request.

Your legal name:

 

Language preference:

Birthdate:

 

Gender: M

F

 

 

 

 

 

 

 

 

 

Your mailing address:

 

 

 

 

Home phone:

 

 

Social Security no. (see Form 3283):

 

Occupation:

 

Work phone:

 

 

 

 

 

 

 

 

 

 

 

Names of witnesses:

 

 

 

 

 

 

 

 

Name and phone number of health insurance company:

 

Name and address of health care provider who treated you for the

 

 

 

injury or illness you are now reporting:

 

 

 

 

 

 

 

 

 

 

 

Were you hospitalized overnight?

Yes

No

 

 

 

 

 

 

Were you treated in the emergency room?

Yes

No

 

 

 

 

 

 

By my signature, I am making a claim for workers’ compensation benefits. The above information is true to the best of my knowledge and belief. I authorize health care providers and other custodians of claim records to release relevant medical records to the workers’ compensation insurer, self-insured employer, claim administrator, and the Oregon Department of Consumer and Business Services. Notice: Relevant medical records include records of prior treatment for the same conditions or of injuries to the same area of the body. A HIPAA authorization is not required (45 CFR 164.512(I)). Release of HIV/AIDS records, certain drug and alcohol treatment records, and other records protected by state and federal law requires separate authorization.

Worker

Completed by

 

signature:

(please print):

Date:

 

 

 

Employer

Complete the rest of this form and give a copy of the form to the worker. Notify your workers’ compensation insurance company within five days of knowledge of the claim. Even if the worker does not wish to file a claim, maintain a copy of this form.

 

Employer legal

 

 

 

 

 

 

 

 

 

 

 

 

 

business name:

 

 

 

 

 

Phone:

 

 

 

FEIN:

 

 

If worker leasing company,

 

 

 

 

 

 

 

 

 

Client

 

 

list client business name:

 

 

 

 

 

 

 

 

 

FEIN:

 

 

Address of principal place

 

 

 

 

 

 

 

 

Insurance

 

 

of business (not P.O. Box):

 

 

 

 

 

 

 

 

policy no.:

 

 

Street address from which

 

 

 

 

 

 

 

 

 

Nature of business in which worker

 

worker is/was supervised:

 

 

 

 

 

ZIP:

 

 

 

is/was supervised:

 

 

Address where

 

 

 

 

 

 

 

 

 

 

 

 

 

event occurred:

 

 

 

 

 

 

 

 

 

 

 

 

 

Was injury caused by failure of a machine or product, or by a person other than the injured worker?

Yes

No

 

 

Were other workers injured?

 

Yes

No

 

 

 

OSHA 300 log case no:

 

 

Date employer

 

Date worker

 

Worker’s

Date worker

 

If fatal, date

 

knew of claim:

 

returned to work:

 

weekly wage: $

hired:

 

 

 

of death:

 

 

Employer

 

 

 

Name and title

 

 

 

 

 

 

 

signature:

 

 

 

(please print):

 

 

 

 

Date:

 

 

 

OSHA requirements: On-the-job fatalities and catastrophes must be reported to Oregon OSHA within eight

801

 

 

hours. Report any accident that results in overnight hospitalization within 24 hours to Oregon OSHA. Call

440-801 (01/10/DCBS/WCD/WEB)

800-922-2689, 503-378-3272, or Oregon Emergency Response, 800-452-0311, on nights and weekends.

 

WC9552A (01-10) WOLTERS KLUWER FINANCIAL SERVICES | UNIFORM FORMSTM

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Ev fields to complete

Note the required data in the section Were you treated in the emergency, Completed by please print, Date, Employer, Complete the rest of this form and, Phone, FEIN Client FEIN, Insurance policy no, ZIP, Nature of business in which worker, If worker leasing company list, Street address from which worker, Address where event occurred, Was injury caused by failure of a, and Yes.

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