Workers Compensation Intake PDF Form - FormsPal

Workers Compensation Intake Form PDF Details

If you're injured on the job, it's important to report the injury as soon as possible. You can do this by filling out a workers compensation intake form. This form will help your employer and the workers compensation insurance company track your claim and provide you with the necessary benefits. There are a few things you should keep in mind when filling out a workers compensation intake form. First, be sure to include all of your contact information so that they can reach you if they have any questions. Also, make sure to describe how the injury occurred and list any treatments or medications you've received for the injury. Finally, sign and date the form so that it's official.

Below are some specifics about workers compensation intake form. You may learn its length, the actual time necessary to fill out the form, the blanks you'll have to fill in, and so on.

Question	Answer
Form Name	Workers Compensation Intake Form
Form Length	5 pages
Fillable?	Yes
Fillable fields	218
Avg. time to fill out	22 min 27 sec
Other names	comp intake form, workers comp intake, wage claim intake form spanish, workers compensation intake form

12

Form Preview Example

WORKERS’ COMPENSATION CASE INTAKE FORM

Date

CLIENT INFORMATION

Client

Address

Phone (H)

(W)

Cell

Date Retainer Agreement Signed

SSN

E-Mail

Date of Birth

Driver’s License

Education

Spouse/Partner’s Name

Spouse/Partner Phone

Dependents

Referred By

Emergency Contacts (Name/Address/Phone)

EMPLOYMENT/INSURANCE/UNION MEMBERSHIP

Primary Employer

Address

Wage

Insurer

Adjuster

Address

Claim No.

Telephone

Managed Care Organization

 Yes

 No

Policy No.

When was the comp insurer notified of the claim being filed?

Date

Date of Hire

Occupation

Currently Working

Scheduled Days Off

Wage Loss Paid

Secondary Employer

Address

Wage

Insurer

Adjuster

Address

Claim No.

Telephone

Managed Care Organization

 Yes

 No

Policy No.

When was the comp insurer notified of the claim being filed?

Date

Has documentation of the wage at the secondary job been obtained?

 Yes  No

Date of Hire

Occupation

Currently Working

Scheduled Days Off

Wage Loss Paid

[Rev 11/13]

PROFESSIONAL LIABILITY FUND (WORKERS’ COMP INTAKE FORM.DOC)

Non-Industrial Carrier						 Yes	 No	Policy No.
Carrier
Address

Private Health Carrier (if any)						 Yes	 No	Policy No.
Carrier
Address

Union Membership						 Yes	 No	Local No.
Union Name
							INJURY
Date of Injury								Claim No.
WCB No.								WCD No.

Body Part(s) Injured

How Did the Injury Occur

Where Did the Injury Occur (City/State)

		PRIOR CLAIMS
Date of Prior Workers’ Comp Claim			Amount of Award $
Date of Prior Workers’ Comp Claim			Amount of Award $
Date Worker’s Statement or Deposition Taken

PREVIOUS MOTOR VEHICLE ACCIDENTS AND OTHER PRIOR INJURIES

[Rev 11/13]

PROFESSIONAL LIABILITY FUND (WORKERS’ COMP INTAKE FORM.DOC)

MEDICAL CONDITIONS PRE-EXISTING THIS INJURY

PRIOR ARRESTS AND CONVICTIONS

MENTAL HEALTH, ALCOHOL, DRUG USE (CURRENT AND HISTORY)

DEADLINES TO CALENDAR

Date of Notice of Closure

Statute Runs

60 days from date of Order

Date of Reconsideration Order*

Statute Runs

30 days from date of Reconsideration Order

Date of Denial*

Statute Runs

60 days from date of mailing of denial

Aggravation Claim

Statute Runs

5 years from date of first Notice of Closure, if disabling;

5 years from date of Notice of Acceptance, if nondisabling

* Request hearing immediately

Date of Opinion and Order

Statute Runs

30 days from date of Opinion and Order

Date of Board Order Mailing

Statute Runs

30 days from date of Order on Review

Date Appellate Brief Due

[Rev 11/13]

PROFESSIONAL LIABILITY FUND (WORKERS’ COMP INTAKE FORM.DOC)

Date of scope of acceptance demand letter					Statute Runs
Date of Director’s Admin. Review Order						60 days from date of demand
					Statute Runs
					60 days from Dir. Admin. Review Order
Date of Medical Services Order					Statute (OAR) Runs
Vocational Services Issue					Statute Runs

WCD

Date Request for Hearing Filed Hearing Date

Date Client Notified

WCB

Date Request for Hearing Filed Hearing Date

Date Client Notified

LIEN ITEMS

□

□

□

Child Support Liens

Medicaid

Welfare Assistance

□

□

□

Unemployment Benefits

Medicare

Private Health Carrier

□

□

□

Social Security Disability

Oregon Health Plan

Other

NAMES OF PHYSICIANS, MEDICAL FACILITIES WHERE TREATED

	Physician or Facility		Address		Phone

REQUESTS FOR RECORDS

Records from treating physician	Date Requested		Rec’d
Hospital records	Date Requested		Rec’d
Other physician records	Date Requested		Rec’d
Other physician records	Date Requested		Rec’d
Document demand to employer	Date Requested		Rec’d
Medical releases obtained	Date Requested		Rec’d

[Rev 11/13]

PROFESSIONAL LIABILITY FUND (WORKERS’ COMP INTAKE FORM.DOC)

THIRD PARTY RESPONSIBILITY

Third Party Potential

Potentially Responsible Party

Theory of Liability

SOL

Notes

WITNESSES

				Interviewed	Subpoenaed
Name					
Address

Telephone
Name					
Address

Telephone
Name					
Address

Telephone
Name					
Address

Telephone

[Rev 11/13]

PROFESSIONAL LIABILITY FUND (WORKERS’ COMP INTAKE FORM.DOC)

How to Edit Workers Compensation Intake Form Online for Free

It is really straightforward to complete the workers compensation patient intake form spaces. Our tool will make it virtually effortless to work with any specific PDF file. Down the page are the primary four steps you need to take:

Step 1: The initial step requires you to choose the orange "Get Form Now" button.

Step 2: As soon as you've accessed the editing page workers compensation patient intake form, you will be able to discover each of the options readily available for the document at the upper menu.

These sections will make up the PDF document that you will be filling out:

stage 1 to filling in workers comp intake

Complete the Primary, Employer Wage, Insurer, Address, Managed, Care, Organization Yes, No Address, Adjuster, Claim, No Telephone, Policy, No Date, Date, of, Hire Currently, Working and Wage, Loss, Paid fields with any information that are requested by the system.

workers comp intake PrimaryEmployer, Wage, Insurer, Address, ManagedCareOrganization, YesNo, Address, Adjuster, ClaimNo, Telephone, PolicyNo, Date, DateofHire, CurrentlyWorking, and WageLossPaid fields to fill out

The system will ask you for details to conveniently submit the area Yes, No Date, of, Hire Currently, Working Wage, Loss, Paid Occupation, Scheduled, Days, Off and Rev.

stage 3 to filling out workers comp intake

The NonIndustrial, Carrier Carrier, Address, Private, Health, Carrier, if, any Carrier, Address, Union, Membership Union, Name Date, of, Injury WC, B, No Body, Parts, Injured How, Did, the, Injury, Occur Yes, No Policy, No and Yes, No section could be used to indicate the rights and responsibilities of both parties.

NonIndustrialCarrier, Carrier, Address, PrivateHealthCarrierifany, Carrier, Address, UnionMembership, UnionName, DateofInjury, WCBNo, BodyPartsInjured, HowDidtheInjuryOccur, YesNo, PolicyNo, and YesNo in workers comp intake

Check the sections Where, Did, the, Injury, Occur, City, State PRIOR, CLAIMS Amount, of, Award and Amount, of, Award and next complete them.

step 5 to finishing workers comp intake

Step 3: If you're done, click the "Done" button to export your PDF document.

Step 4: In order to prevent possible forthcoming complications, take the time to have up to several copies of any form.

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