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Workmens Compensation Claim Form
Please complete all questions as fully as possible
Trade or Business
The Injured Person
Period in Service
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 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.