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COMPENSATION WORKERS COMPENSATION and APPLICATION Fax 262.798.5040 EMPLOYERS LIABILITY INSURANCE APPLICATION Te l 262.798.5050 20935 Swanson Drive Waukesha, Wisconsin 53186-2057 Insured Account Number:
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How to fill out compensation workers compensation and:

01
Begin by gathering all relevant information such as employee details, employer information, and the details of the injury or illness that occurred at work.
02
Fill out the employee section of the form, providing personal information like name, address, and contact details.
03
Proceed to the employer section, providing details such as the company's name, address, and contact information.
04
Fill in the details of the injury or illness that happened at work, including the date and time it occurred, the location, and a description of what happened.
05
Provide information on any medical treatment received and the name of the healthcare provider or facility.
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If there were any witnesses to the incident, mention their names and contact details.
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Lastly, sign and date the form, ensuring that all necessary fields have been filled out correctly.

Who needs compensation workers compensation and:

01
Employees who have suffered a work-related injury or illness and require financial support during their recovery.
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Employers who are legally obligated to provide workers compensation benefits to their employees in case of on-the-job injuries or illnesses.
03
Insurance companies or third-party administrators responsible for managing workers compensation claims and ensuring appropriate compensation is provided to eligible individuals.
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Workers compensation is a form of insurance providing wage replacement and medical benefits to employees injured in the course of employment.
Employers are required to provide workers compensation insurance coverage for their employees.
Employers can fill out workers compensation forms provided by their insurance carrier or state workers compensation board.
The purpose of workers compensation is to provide financial protection for employees who are injured or become ill as a result of their work.
Employers must report details of the injury or illness, medical treatment received, and wages lost due to the injury.
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