REPORT A CLAIM
*yellow fields are required
Employee Social Security #:
--
 Date of Injury:
 Employee First Name:
Employee Last Name:
Street Address:
City:
 State:
 Zip Code:
County:
 Phone Number:
-
 Employee:
 Date of Birth:
Number of Dependents:
Occupation or Job Title:
Employment Status:
  
 Employer:
 Policy Number:
 Street Address:
City:
 State:
  Zip Code:
Phone Number:
- 		 
County:
  
Contact First Name:
 Contact Last Name:
Contact Phone Number:
- 		Contact Fax Number:
- 		Contact Email:
Did injury or illness occur on employer's premises?
 State of Injury:
Address where injury occurred if different than above?
Street Address:
City:
 State:
 Zip Code:
Time employee began work (HH:MM):
: 		Time of occurrence (HH:MM):
:
Last Date Worked:
 Full pay for day of injury?
Date Disability Began:
 Date Employer Notified:
Date Returned to Work (if applicable):
Date of Hire:
Type of Injury:
 Part of Body Affected:
Cause of Injury:
Were safeguards or safety equipment provided?
 Were safeguards or safety equipment used?
All equipment, materials, or chemicals employee was using when accident
or illness exposure started:
How injury or illness/abnormal health condition occurred. Describe the sequence
of events and include any objects or substances directly responsible:
If fatal, give date of death:
Witness First Name:
 Witness Last Name:
Witness Phone Number:
-
Health Care Provider

Physician First Name or Health Care Provider:

Physician Last Name:

Street Address:
 		Initial Treatment:
No Medical Treatment/Minor by Employee
Health Care Provider
Panel Physician
Employee Physician
City:
 State:
 Zip Code:
Person Completing This Form
(if not the same as contact)
Name:

Title:

Phone:
( )  
 
Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165.

Step 1 Step 2 Step 3
In order to properly document your records you need to first "Print Form" and then "Acknowledge & Submit". Once you press "Acknowledge & Submit" you cannot go back and print a copy of the completed form.
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