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CITY OF EL PASO WORKERS COMPENSATION PROGRAM Completion and Distribution of Forms INJURED EMPLOYEE STATEMENT1. Have Employee fill out INJURED EMPLOYEE STATEMENT form as soon as he reports an injury unless
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How to fill out injured employee statement form

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How to fill out injured employee statement form

01
How to fill out injured employee statement form:
02
Obtain a copy of the injured employee statement form from your employer or the workers' compensation office.
03
Begin by providing your personal information, such as your name, address, contact number, and employee ID.
04
Specify the date and time of the incident in which you were injured.
05
Describe the nature of the injury, including the body part affected and the cause of the injury.
06
Provide details about the incident itself, including the location, any witnesses present, and what actions were being performed at the time.
07
If you received any medical treatment for the injury, include information about the healthcare provider, the treatment received, and any medications prescribed.
08
Sign and date the form, indicating that the information provided is true and accurate.
09
Submit the completed form to your employer or the workers' compensation office as instructed.

Who needs injured employee statement form?

01
The injured employee statement form is needed by:
02
- Employees who have sustained work-related injuries and are seeking workers' compensation benefits.
03
- Employers who need to document and report workplace injuries for insurance and legal purposes.
04
- Workers' compensation offices or insurance companies who require the form as part of the claims process.
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The injured employee statement form is a document used by employees to report injuries sustained in the workplace. It typically includes details about the incident, the nature of the injury, and any immediate medical treatment received.
The injured employee is required to file the injured employee statement form, typically within a specified timeframe following the workplace incident.
To fill out the injured employee statement form, the employee should provide accurate information regarding the incident, including the date and time of the injury, a description of how it occurred, details of the injury, and any witnesses present. It should be signed and dated by the employee.
The purpose of the injured employee statement form is to document the incident and injury, serving as a formal record that can be used for workers' compensation claims and to ensure compliance with workplace safety regulations.
The information that must be reported on the injured employee statement form includes the employee's personal information, details of the injury, circumstances of the incident, medical treatment received, and any witnesses.
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