Get the free Supplemental Report of Injury - Texas Department of Insurance - tdi texas

CLAIM # Carrier # SUPPLEMENTAL REPORT OF INJURY Part I EMPLOYER INFORMATION 2. Employer phone # 1. Employer business name 3. Employer mailing address 4. Insurance carrier name 5. Does the employer

How to fill out supplemental report of injury

How to fill out the supplemental report of injury:

1. Obtain the supplemental report of injury form from your employer or the relevant authority.
2. Fill in your personal information such as your name, address, contact number, and social security number.
3. Provide details about the injury incident, including the date, time, and location of the occurrence.
4. Describe the nature of the injury, whether it was a slip and fall, a strain, a cut, or any other type of injury.
5. Explain the circumstances or events that led to the injury. Be as specific and detailed as possible.
6. Provide information about any witnesses to the incident, including their names and contact details if available.
7. If there were any immediate medical treatments received, describe them and include the names of the healthcare professionals or facilities involved.
8. Indicate if you have already filed a standard injury report and provide the relevant details.
9. Sign and date the supplemental report of injury form.
10. Keep a copy of the completed form for your records and submit the original to your employer or the appropriate office.

Who needs a supplemental report of injury:

1. Employees who have experienced a work-related injury or illness that was not adequately captured in the initial injury report.
2. Individuals who have suffered from an aggravation or worsening of a previously reported work-related injury.
3. Employees who have obtained additional information or documentation relevant to their previous injury claim.

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What is supplemental report of injury?

A supplemental report of injury is a document that provides additional information and updates related to a previously filed injury report.

Who is required to file supplemental report of injury?

The employer or their representative is required to file a supplemental report of injury when there are significant changes or new developments regarding an already reported injury.

How to fill out supplemental report of injury?

To fill out a supplemental report of injury, you need to provide accurate and complete information about the changes or new developments related to the previously reported injury. This can include updated medical information, changes in treatment, or any additional impacts on the employee's ability to work.

What is the purpose of supplemental report of injury?

The purpose of a supplemental report of injury is to ensure that the workers' compensation system has up-to-date and accurate information about the employee's injury. It allows for better management of the injury claim and appropriate determination of benefits.

What information must be reported on supplemental report of injury?

The information that must be reported on a supplemental report of injury includes any changes to the employee's condition, treatment updates, new symptoms, or any other significant developments related to the previously reported injury.