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NOTIFICATION OF WORKERS COMPENSATION CLAIM Please send this completed form to work comp×phmic.com or fax to 9253497631.EMPLOYER INSURED NAMEFEDERAL TAX IDADDRESSLOCATION # D/B/A NAMEUNEMPLOYMENT

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How to fill out notification of workers compensation

01

Start by gathering all the necessary information about the injured worker, including their full name, address, and contact details.

02

Fill out the employee's job title, department, and hire date.

03

Provide a detailed description of the injury or illness and how it occurred. Include the date, time, and location of the incident.

04

Attach any supporting documentation, such as medical records or witness statements, to substantiate the worker's claim.

05

Complete the employer portion of the form, including the company's name, address, and contact information.

06

Sign and date the notification form, certifying that all the information provided is true and accurate.

07

Keep a copy of the completed form for your records.

08

Submit the notification of workers' compensation to the appropriate authorities or insurance provider as per your jurisdiction's requirements.

Who needs notification of workers compensation?

01

Workers who have suffered a work-related injury or illness and are seeking compensation benefits.

02

Employers or companies responsible for reporting and addressing workers' compensation claims.

03

Insurance providers or authorized agencies involved in handling and processing workers' compensation claims.

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