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CAYUGA COUNTY VOLUNTEER FIREFIGHTER AFFIDAVIT OF INJURY To be filled out by the volunteer within 48 hours of injury (Submit to supervisor in charge at time of injury) 1. Volunteer Name:Social Security

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How to fill out employees affidavit of injury

01

Start by obtaining a copy of the employee's affidavit of injury form.

02

Provide the necessary information at the top of the form, such as the employee's name, social security number, and contact details.

03

Indicate the date and time of the injury in the corresponding section.

04

Describe in detail how the injury occurred, including the location, events leading up to the injury, and any witnesses present.

05

If medical treatment was sought, provide information about the healthcare provider, including their name, address, and contact details.

06

Attach any relevant medical documents, such as doctor's reports or hospital records, to support the claim.

07

Sign and date the affidavit, acknowledging that the information provided is true and accurate to the best of your knowledge.

08

Submit the completed form to the appropriate department or authority responsible for processing injury claims.

Who needs employees affidavit of injury?

01

Employees who have suffered a work-related injury and wish to file a claim for compensation or benefits typically need to complete the employee's affidavit of injury.

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What is employees affidavit of injury?

Employees affidavit of injury is a written statement provided by an employee detailing the circumstances of an injury sustained while on the job.

Who is required to file employees affidavit of injury?

Employees who have been injured on the job are required to file employees affidavit of injury.

How to fill out employees affidavit of injury?

Employees can fill out employees affidavit of injury by providing accurate and detailed information about the injury they sustained while on the job.

What is the purpose of employees affidavit of injury?

The purpose of employees affidavit of injury is to document and report any work-related injuries for the purpose of workers' compensation claims.

What information must be reported on employees affidavit of injury?

Information such as the date, time, location, and nature of the injury, as well as any witnesses present, must be reported on employees affidavit of injury.

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