Get the free EMPLOYEE'S STATEMENT OF INJURY AND CLAIM FOR COMPENSATION

State of New York WORKERS COMPENSATION BOARD C3 EMPLOYEE IS STATEMENT OF INJURY AND CLAIM FOR COMPENSATION Answer All Questions Fully Type or Print Clearly WEB Case Number (if known): A. INJURED PERSON

How to fill out employees statement of injury

How to fill out employees statement of injury?

1. Start by providing your personal information: The first step in filling out the employee's statement of injury is to provide your personal information. This includes your full name, address, contact number, and employee identification number.
2. Describe the date and time of the injury: In the form, you will need to clearly state the date and time when the injury occurred. This information is crucial for accurately documenting the incident.
3. Provide details about the injury: Describe the nature of your injury in detail. Explain how the injury occurred, the specific body part affected, and any visible symptoms or pain you are experiencing. The more specific and detailed you are, the better it will be for the record.
4. Mention the location of the injury: Identify the exact location where the injury occurred. This could be the address of your workplace, a specific site within the workplace, or any other relevant information that can help identify the location accurately.
5. Include information about witnesses, if any: If there were any witnesses to the incident, make sure to include their names and contact information in the statement. Their testimonies can support your claim and provide additional evidence if needed.
6. Indicate any prior injuries or medical conditions: If you had any pre-existing injuries or medical conditions that might have been aggravated by the incident, it is important to mention them in the statement. This will help provide a comprehensive overview of the situation.
7. Sign and date the statement: Once you have completed all the necessary information, carefully read through the statement and ensure its accuracy. Sign and date the statement to affirm that the information provided is true and complete to the best of your knowledge.

Who needs employees statement of injury?

1. Employers: Employers need the employee's statement of injury to accurately document and understand the circumstances surrounding the incident. It helps them investigate and address any workplace safety issues, prevent future accidents, and comply with legal requirements.
2. Insurance companies: Insurance companies often request the employee's statement of injury to process workers' compensation claims. It helps them evaluate the validity of the claim and determine the extent of coverage and benefits to be provided.
3. Legal representatives: In case of disputes or legal proceedings related to the injury, attorneys and legal representatives rely on the employee's statement of injury as crucial evidence. It supports the injured employee's claim and helps build a strong case for compensation.

Note: The specific individuals or entities that require the employee's statement of injury may vary depending on the jurisdiction, industry, and specific circumstances of the incident. It is advisable to consult with your employer, legal counsel, or relevant authorities to determine the appropriate parties who need this information in your specific case.

For pdfFiller’s FAQs

What is employees statement of injury?

Employees statement of injury is a document where the employee provides details about their work-related injury or illness.

Who is required to file employees statement of injury?

The employee who has experienced a work-related injury or illness is required to file the employees statement of injury.

How to fill out employees statement of injury?

The employee must provide information about the injury, how it occurred, when it occurred, and any medical treatment received in the employees statement of injury.

What is the purpose of employees statement of injury?

The purpose of employees statement of injury is to document and report work-related injuries or illnesses for the purposes of workers' compensation.

What information must be reported on employees statement of injury?

Information such as the date and time of the injury, the location where the injury occurred, and a description of how the injury occurred must be reported on employees statement of injury.

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