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STATE OF HAWAII DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DISABILITY COMPENSATION DIVISION FORM WC5 (REV 7×92) EMPLOYEES CLAIM FOR WORKERS COMPENSATION BENEFITS INJURED PERSON Name Address Occupation
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How to fill out employee39s claim for workers
How to fill out employee's claim for workers?
01
Begin by gathering all necessary information, such as the employee's full name, address, contact information, and social security number.
02
Next, provide details about the incident or injury the employee is claiming for. Include the date, time, and location of the incident, as well as a description of what happened and any contributing factors.
03
If applicable, attach any supporting documents, such as medical reports, witness statements, or photographs that can provide evidence for the claim.
04
Provide information about any medical treatment or expenses incurred as a result of the incident. Include details about the treating physician or hospital, dates of treatment, and any costs involved.
05
Fill out the section regarding lost wages or income. This may involve providing an estimate of the amount of time the employee was unable to work, their normal rate of pay, and any compensation received during that period.
06
Review the entire claim form for accuracy and completeness before submitting it to the appropriate party, such as the employer's HR department or the workers' compensation board.
Who needs employee's claim for workers?
01
Employees who have sustained work-related injuries or illnesses and wish to seek compensation or benefits.
02
Employers who need to document and process employees' claims for workers' compensation insurance or other benefits.
03
Insurance companies or workers' compensation boards responsible for reviewing and deciding on the validity of employee claims and providing necessary compensation or benefits.
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What is employee39s claim for workers?
Employee's claim for workers is a formal request or application made by an employee to receive compensation for work-related injuries or illnesses.
Who is required to file employee39s claim for workers?
The employee who has suffered a work-related injury or illness is required to file the claim for workers.
How to fill out employee39s claim for workers?
To fill out the employee's claim for workers, the employee must provide detailed information about the injury or illness, when and where it occurred, and any witnesses.
What is the purpose of employee39s claim for workers?
The purpose of the employee's claim for workers is to ensure that the employee receives compensation for medical expenses, lost wages, and any other damages resulting from a work-related injury or illness.
What information must be reported on employee39s claim for workers?
The employee must report details such as the date, time, and location of the injury or illness, the nature of the injury or illness, and any witnesses or evidence supporting the claim.
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