Employee Claim

A. Your Information (Employee)

WCB Case Number (if you know it):

* First Name: * Last Name: MI:

* Mailing Address:

Address Line 2:

* City: State: Zip Code: Country:

* Date of Birth:

Social Security Number:

* Phone Number:

* Gender:

M F X

* Will you need a translator if you have to attend a Board hearing?

Yes No

B. Your Employer(s)

* Employer when injured:

* Your Work Address:

Address Line 2:

* City: State: Zip Code: Country:

Phone Number:

Date you were hired:

Supervisor's First Name: Last Name:

Did you have more than one employer at the time of your injury/illness? Yes No

List names/addresses of any other employer(s) at the time of your injury/illness:

Name:

Address:

Address Line 2:

City: State: Zip Code: Country:

Did you lose time from work at the other employment(s) as a result of your injury/illness? Yes No

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C. Your Job on the date of the injury or illness

* What was your job title or description?

What types of activities did you normally perform at work?

If Other, Specify:

* What was your gross pay (before taxes) per pay period?

* How often were you paid?

* Did you receive lodging or tips in addition to your pay?

Yes No

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D. Your Injury or Illness

* Date of injury or date of onset of illness:

Time of injury: AM PM

* Where did the injury/illness happen? (e.g., 1 Main Street, Pottersville, at the front door)

* Was this your usual work location?

Yes No

* What were you doing when you were injured or became ill? (e.g., unloading a truck, typing a report)

* How did the injury/illness happen? (e.g., I tripped over a pipe and fell on the floor)

* Explain fully the nature of your injury/illness; list body parts affected (e.g., twisted left ankle and cut to forehead):

* Was an object (e.g., forklift, hammer, acid) involved in the injury/illness?

Yes No

* Was the injury the result of the use or operation of a licensed motor vehicle?

Yes No

* Have you given your employer (or supervisor) notice of injury/illness?

Yes No

* Did anyone see your injury happen?

Yes No Unknown

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E. Return To Work

* Did you stop work because of your injury/illness?

Yes No

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F. Medical Treatment For This Injury or Illness

* Did you receive treatment for your injury or illness?

Yes None Received

What was the date of your first treatment?

Were you treated on site? Yes No

Where did you receive your first off site medical treatment for your injury/illness? None Received Emergency Room Doctor's Office Clinic/Hospital/Urgent Care Hospital Over 24 Hours

Are you still being treated for this injury/illness? Yes No

Give the name and address of the doctor(s) treating you for this injury/illness.

Add additional doctor's if there is more than one doctor still treating you for this injury/illness

First Name: Last Name:

Address:

Address Line 2:

City: State: Zip Code: Country:

Phone Number:

* Have you had another injury to the same body part, or a similar illness?

Yes No

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G. Prepared By

Any person who knowingly and with INTENT TO DEFRAUD presents, causes to be presented, or prepares with knowledge or belief that it will be presented to, or by an insurer, or self-insurer, any information containing any FALSE MATERIAL STATEMENT or conceals any material fact, SHALL BE GUILTY OF A CRIME and subject to substantial FINES AND IMPRISONMENT.

Please Note: If you have retained a legal representative at the time of filling out this on-line EC-3, then you must notify your legal representative that they must complete and sign form OC-400.5 (Attorney/Representative's Certification of form C-3) and mail it to the Board.

An individual may sign on behalf of the employee only if he or she is legally authorized to do so and the employee is a minor, mentally incompetent or incapacitated.

* Prepared By:

Employee On Behalf of Employee

* First Name: * Last Name: MI:

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