Guide to Workers Compensation Collect Claims Information

1. Information about the employee

2. Information about the injury

• Date of the injury
• Date of death, if applicable
• State where injury occurred
• Nature (description) of injury (sprain, fracture)
• Affected body parts
• Source of injury (machine, hand tool)
• Type of injury (fall, struck by, overexertion, repetitive motion trauma)
• Witnesses
• Work process involved (lifting, carrying)
• Industry
• Division
• Plant or location
• Department
• Supervisor
• Job description
• Time of day
• Shift

3. Information about the claim

• Date [Organization Name] was notified
• Who was notified?
• Who did the notification?
• Date [Organization Name]'s workers' compensation claims department was notified
• Date [Organization Name]'s insurance company was notified
• Date the state agency was notified
• State claim case number
• Employee's average weekly wage
• Employee's benefit rate
• Treating health care providers
• Health care costs
• Other benefits lost (Did [Organization Name] stop paying vacation, health benefits, etc.?)
• Other benefits received
• Offset for other benefits
• Date the disability began
• Date of first benefit payment
• Projected return-to-work date
• Date the claim was closed
• Date the employee reached maximum medical improvement
• Employee's impairment rating
• Work days the employee lost due to the injury
• Total benefits paid
• Benefit reserves available
• Vocational rehabilitation activity
• Was subrogation involved?
• Is there Second Injury Fund potential?

4. If litigation is involved

• Defense attorney or law firm
• Claimant's attorney or law firm
• Judge
• Cost of litigation (Is [Organization Name] spending more than it is paying?)
• History of the dispute
• Settlement

Reprinted with permission. © CCH