What information do I need to collect before filing a workers' compensation claim?

When your employee gets injured on the job, you need to collect and report information right away so your insurance adjuster can make an accurate determination and your employee can get the help they need.

Instruct all managers and supervisors to collect the following pieces of information immediately upon learning of an employee's work-related injury or illness, regardless of whether the employee asks for or denies medical attention or requests to be excused from the remainder of their shift.

1. Injured person's demographic info

  • Full legal name
  • Primary language
  • Phone number
  • Email address
  • # of dependents

2. Incident details

  • Time employee began work
  • Date of injury/illness
  • Time of occurrence
  • Date employer was notified
  • On-site contact name and phone number
  • Description of injury/illness
  • Whether the injury or illness occurred on employer's premises
  • Department or location where accident or illness occurred
  • Work process the employee was engaged in when accident or illness exposure occurred
  • How injury or illness/abnormal health condition occurred. Describe the sequence of events and include any objects or substances that directly injured the employee or made the employee ill.
  • Date returned to work (especially if the finished their shift)
  • Were safeguards/protective equipment provided? If so, were they utilized?

3. Treatment Details

  • Hospital or off-site treatment facility name and address
  • Initial treatment
    • No medical treatment
    • Minor, treated by employer
    • Minor, treated at clinic/hospital
    • Emergency care
    • Hospitalized for more than 24 hours
    • Future major medical - lost time anticipated
    • Other
  • Witness names and phone numbers

    4. Written statement from employee indicating:

    • Nature of the injury or illness
    • How they were injured or sickened
    • Where the injury or illness occurred
    • When they realized they were injured or ill
    • Whether and when they intend to seek medical attention
    • Current phone number, email address and mailing address
    • Name and phone number of an emergency contact