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WORKERS COMPENSATION CLAIM TRANSMITTAL FORM To: Cannon Cochran Management Services, Inc. 3333 Greenville Road, Suite 550 Lisle, IL 60532 From: Claimant: 1) Illinois Form 45 and the Supervisors Investigation
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How to fill out workers compensation claim transmittal

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How to Fill Out Workers Compensation Claim Transmittal:

01
Start by entering your personal information, such as your name, address, and contact details, in the designated fields on the form.
02
Next, provide the name and address of the workers' compensation insurance carrier or self-insured employer.
03
Fill in the claim number and policy number, if applicable.
04
Indicate the injured worker's name, address, and contact information.
05
Provide the date of injury or onset of illness and the injured worker's job title or occupation.
06
Describe the nature of the injury or illness and the body part(s) affected.
07
Include details about the medical treatment received, such as the name and address of the healthcare provider.
08
If applicable, mention any pre-existing conditions that may be related to the current injury or illness.
09
Attach any supporting documents, such as medical reports or incident reports, if required.
10
Sign and date the transmittal form to certify that the information provided is accurate and complete.

Who Needs Workers Compensation Claim Transmittal:

01
Employers: Employers who are required by law to provide workers' compensation insurance coverage for their employees may need to complete a workers compensation claim transmittal form.
02
Injured Workers: Workers who suffer from a work-related injury or illness may need to fill out a workers compensation claim transmittal to initiate the claims process and report the incident to their employer's insurance carrier or self-insured employer.
03
Insurance Carriers or Self-Insured Employers: Workers compensation claim transmittal forms are necessary for insurance carriers or self-insured employers to receive and process workers' compensation claims filed by injured workers.
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Workers compensation claim transmittal is a form or document used to transmit workers' compensation claims from the employer to the insurance carrier or third-party administrator.
Employers are typically required to file workers compensation claim transmittal when a worker's injury or illness occurs on the job.
Workers compensation claim transmittal is typically filled out by providing details of the injured worker, including their name, date of injury, description of the injury, and any medical treatment received.
The purpose of workers compensation claim transmittal is to notify the insurance carrier or third-party administrator of a worker's compensation claim and to initiate the claims process.
Information such as the injured worker's name, date of injury, description of the injury, employer information, and any medical treatment received must be reported on workers compensation claim transmittal.
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