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.

QuestionAnswer
Form NameWorkers Compensation Intake Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesworkers comp designated provider letter, workers compensation patient intake form, worker comp intake form template, comp intake form

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)

Watch Workers Compensation Intake Form Video Instruction

Workers Compensation Intake Form isn’t the one you’re looking for?

Related Documents

  • Workers Permit Maryland

    "... Complete your section on the application. Print it and ensure it's legible. Have your guardian or parent sign the application. Then, submit the online application at www.dllstate.md.us labor.empm.shtml. Provide proof of your age and the ..."

  • Work Permit Form

    "... Work permit data sheet: Information on minora Please print last name, street code and county. Parent guardian must also be present. Employer information can be printed at www.dolstatega.gov. Select child labor. Enter the name of ..."

  • Workers Compensation C 4 Form

    "... Patient name Social Security no address Address of Insurance Carrier Name Attending Doctor Name address Provider Authorization No Telephone No fax Requested Response if service denied. All questions must be answered fully by the state ..."

  • Workers Compensation Injury Report

    "... Workers compensation claim number OSHA log purpose code jurisdiction code claim number insured report number Employer name employer address in the cl Zip location Industry code address of the employer. If different from the employer's ..."

Related Resources

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .