Women’s Compensation Claim Form

Full Name *

First

Last

Address

Occupation

Job Description

Age

Marital Status

Amount of Weekly Earnings

How long has He been in your Employment?

Date and Time of Accident

Date

Time

Place of Accident

State the work the workman was engaged in at the time of the accident.

Was the injured worker under the influence of alcohol or any drug?

Date on which injured worker ceased work consequent upon the accident.

Date resumption of work

Please give a full description of how the accident happened

Please state the exact nature of injuries sustained by the worker.

Was the accident caused by the negligence of the injured worker or his/her co-worker? YES/NO, If yes, Please explain.

Name and address of witness.

I/We declare that the above statement is true in all respects to the best of knowledge and behalf and we undertake to give all information and assistance as the company may require.

Date

File Upload

Click or drag a file to this area to upload.

Name and Signature of Policyholder.

Solid Protection

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