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Worker Wage and Employment Information
Note: Please send any Supervisor or witness statements and/or Report of Accident you have on file to
[email protected]
Fields marked with * are required
Claim Information
Claimant’s Full Name
*
Claim Number
*
Employer Name
*
Account/Policy No. claim should be assigned to
Comments / Concerns
Do you have any questions, comments or concerns regarding this claim?
Employment Information
Employee’s Job Title
*
Social Security Number
*
Date of Birth
*
Date of Hire
*
End Date
This worker was hired to work on a temporary basis
Name of Temporary Project
Project Start Date
Project End Date
This worker was dispatched by a union
Union Name
Employment Information
Date of Injury or last occupational exposure (OD)
*
Location where the injury/OD occurred
*
When was the injury reported?
*
Who was the injury reported to?
*
What time was the injury reported?
*
Description of how the incident occurred
*
Body part(s) injured or exposed, including side of body
*
Wage Information
If your employee has hours or wages that vary, including if they work overtime or are paid by piece or job, please send payroll records to
[email protected]
. We request 12 months payroll prior the date of injury. Or as much as you have, if they have worked less than 12 months.
Rate of Pay
*
Hours Per Day
*
Days Per Week
*
Multiple rates of pay?
Units of work?
Tips?
Amount $
Per
Select...
Hour
Day
Week
Month
Fuel?
Amount $
Per
Select...
Hour
Day
Week
Month
Housing/board?
Amount $
Per
Select...
Hour
Day
Week
Month
Commision?
Amount $
Per
Select...
Hour
Day
Week
Month
Bonus in the 12 months prior to the date of injury?
Amount $
Per
Select...
Hour
Day
Week
Month
Bonus Period Start Date
Bonus Period End Date
Overtime in the 12 months prior to the date of injury?
No. of overtime hours
Will the injured worker will be kept on salary for this industrial injury?
*
Select...
Yes
No
Note: kept on salary (wage replacement benefits) excludes: vacation pay, sick leave, holiday pay, paid time off, or similar types of compensation
Health Care Benefit Information
Health care benefits were being paid for the worker and/or the worker’s family at the time of injury
If checked, what amount did you pay for health care benefits only? (do not include pensions, disability insurance or other considerations) $
Per
Select...
Hour
Day
Week
Month
Employer-paid health care coverage has ended
If checked, what was the last date covered?
If payments for health care benefits are ongoing but there is an anticipated coverage end date, please provide the date
Health benefits are managed by a trust or union
Trust/Union Name
Phone Number
Return To Work Information
The injured worker missed time from work
If checked, what specific dates were missed?
Light duty work will be available if the worker is released to modified duty
Light duty comments?
The injured worker has returned to work
Date last worked
Date returned to work
If the injured worker has returned to a light duty position, how many hours per day?
How many days per week?
Position
Select...
Full (no restrictions)
Modified Duty Position
Finishing Up
Completed by
*
Date
*
Phone Number
*
Email Address
*
