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Workmens Compensation Claim Form

 

Please complete all questions as fully as possible

Employer Details

Policy Number
Name Trade or Business
Postal Address Physical Address
Telephone No E-mail ID

The Injured Person

Name Age
Marital Status Occupation
Nationality Period in Service

Other Details

Is the injured person in your employ? If not, give name and address of Contractor State fully the work upon which he/she was engaged in at the time of the accident
Accident Place Accident Date ∓ Time
Date the injured person ceased work How did the accident occur?
When and whom was the accident first reported to?  If accident happened in connection with any machinery give name of machine and state part causing accident
State names of any witness  State the nature of the injuries
Was the injured under the influence of drugs or drink or was he/she guilty of any misconduct or breach of orders or rules? If yes, please explain fully?
Was the accident due to anyone’s negligence? If so, give particulars of persons involved.  Is the injured able to perform any part of their duties?
What is the probable period of disablement?     
Nb: The claim is to be supported by an instruction from the commissioner of labor along with all the forms and documents that may be required by the insurer.