McKinley Law - WORKERS COMPENSATION CLAIM FORM

WORKERS COMPENSATION CLAIM FORM

Part 1: YOUR PARTICULARS
Full name:
Address:
Email:
Telephone:
Date of birth:
Occupation:

Part 2: PARTICULARS OF ACCIDENT
Approx. date of the accident:
General description of your injuries and how they were caused:
Details of treatment received:

Part 3: DISABILITIES AND EFFECTS OF THE ACCIDENT
How have your injuries affected you?

Part 4: EMPLOYMENT DETAILS
Name of employer (at date of injury):
Name of employer's insurance agent for workers compensation claims:
Are you currently in receipt of weekly compensation payments?	Yes No
Have you received any other compensation payments? If so, please provide details: