Claim Reporting - Trustpoint Insurance

Worker's Compensation Loss Details

Insured Report Number

If you have an internal report number assigned to this incident, please enter it here.

OSHA Case Number

If you have reported this incident to OSHA, please enter the case number here.

Employee and Wage Information

Employee Name (Last, First, Middle)*

Phone

Employee Email

Employee Address

Street Address Address Line 2 City State ZIP Code

Occupation/Job Title*

Employment Status*

Employee Worker's Compensation Class Code

eg. 8810 Clerical

Date Hired

State Hired*

Social Security Number

Date of Birth

Sex*

Male
Female
Unknown

Marital Status

Single/Divorced
Married
Separated
Unknown

# of Dependents

Rate

Per*

Average Weekly Rate

# Days Worked/Week

Time employee started work the day of accident.

: HH

MM

Did employee miss any time from work?*

Yes
No

Future Major Medical / Lost Time Anticipated?*

Yes
No

Last date worked due to injury.

Date returned (or expected) to work.

Did salary continue?

Yes
No

Injury and Treatment Information

Initial treatment administered to employee.*

Physician's Name*

Physician's Contact Information*

Hospital/Clinic Name*

Hospital/Clinic Contact Information*

Did this accident result in death or disability to the employee.*

Yes - Death
Yes - Disability
No

Date of Death*

Date Disability Began*

Injury Type*

Specific Injury
Occupational Disease / Cumulative Injury
Multiple Injuries

Specific Injury Types*

Occupational Disease / Cumulative Types*

Multiple Injury Types*

Body Part Injured*

Head Injury*

Neck Injury*

Upper Extremities Injury*

Trunk Injury*

Lower Extremities Injury*

Multiple Body Parts Injury*

Cause of Injury*

Burn/Scald - Heat/Cold Exposure Cause of Injury*

Caught In, Under, or Between Cause of Injury*

Cut, Puncture, Scrape Cause of Injury*

Fall, Slip or Trip Cause of Injury*

Motor Vehicle Cause of Injury*

Strain Cause of Injury*

Striking Against Cause of Injury*

Struck By Cause of Injury*

Miscellaneous Cause of Injury*

Rubbed or Abraded Cause of Injury*

Department / Location*

Describe the department or specific part of the premises the employee was working in at the time of the accident/injury.

Specific activity/work process employee was engaged in when the accident or illness exposure occurred.

All equipment, materials or chemicals employee was using when accident or illness exposure occurred.

Were safeguards or safety equipment provided?*

Yes
No

Were they used?*

Yes
No

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.

Let Trustpoint Insurance help you reduce the impact of claims.

CLAIM REPORTING FORM

Step 1 of 9 - General Policy

Policyholder and Contact Information

Date/Time and Type of Loss

Insurance Policy Information

Property Loss Details

Liability Loss Details

Automobile Loss Details

Automobile Loss Details - Continued

Worker's Compensation Loss Details

Witness Information

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