Workers Comp Form « Lamb Financial Group

Workers Comp Form

Liability Claim | Property Loss | Workers Comp

The following information is required to submit a general liability claim. All information must be completed. Should you require assistance to complete this form, please contact your service representative.

Insured

Name:
Address:
City:
State:
Zip:
Home Phone:
Business Phone:
Email:

Occurence / Treatment Information

Date of Occurrence: (mm/dd/yyyy)
Time of Occurrence:
Date Last Worked: (mm/dd/yyyy)
Date Disability Began: (mm/dd/yyyy)
Date Employer Notified: (mm/dd/yyyy)
Date Returned To Work: (mm/dd/yyyy)
If Fatal, Date of Death: (mm/dd/yyyy)
Describe Injury or Illness:
Part/s of Body Affected:
Department or Location Occurred:
List Equipment, Materials or Chemicals Used When Occurred:
Specific Activity Employee Was Engaged in or Exposed to (eg. cutting metal):
Work Process Employee was Engaged In (eg. building maintenance):
How Injury Occurred. Describe Sequence of Events Including Objects or Substances That Injured the Employee or Made Him Ill:
Initial Treatment

Physician / Health Care Provider Information

Name:
Address:
City:
State:
Zip:

Employee / Wage Information

Name:
Address:
City:
State:
Zip:
Date of Birth:
# Dependents:
Sex:
Social Security #:
Marital Status:
Dated Hired:
State of Hire:
Occupation / Job Title:
Employment:
Salary / Rate:
Avg. Weekly Wages:
# Days Worked/Week:
Full Pay Day of Injury:
Did Salary Continue?:

Hospital Information

Name:
Address:
City:
State:
Zip:

Witness Information

Witness 1:
Witness 1 Phone:
Witness 2:
Witness 2 Phone:

IMPORTANT:
In addition to submitting this form, please send any and all additional information including:

- Police Reports
- Hospital Reports
- Internal Incident Reports

You may also print and fax this form for processing to:
718-389-4300

Lamb Financial Group

insurance designed for human service organizations

Workers Comp Form