Get the free Employee's Report of Claim (Form BWC-117)

Please complete all date fields with the MM/DD/YYY format. Print Reset Form Fill-In Instructions EMPLOYEE'S REPORT OF CLAIM Michigan Department of Consumer & Industry Services Bureau of Workers' &

How to fill out employee39s report of claim

1. To fill out an employee's report of claim, start by gathering all relevant information and documentation related to the incident or injury. This may include incident reports, witness statements, medical records, and any other evidence that supports the claim.
2. Next, carefully review the form and ensure that you understand each section and what information is required. Pay attention to details such as the employee's personal information, the date and time of the incident, and a thorough description of what happened.
3. Provide a clear and concise account of the incident or injury, including any contributing factors or events that may have led to it. Be honest and accurate in your statement, as any inconsistencies or false information can affect the credibility of the claim.
4. If there were any witnesses to the incident, include their names and contact information in the designated section. Witness statements can provide valuable evidence to support the claim and may be necessary for further investigation.
5. If applicable, provide details of any medical treatment received as a result of the incident. This includes the names of healthcare professionals, dates of treatment, and any relevant medical documentation. Make sure to include any ongoing treatment or future appointments that may be required.
6. Finally, review the completed form for accuracy and completeness before submitting it to the appropriate person or department. It is important to submit the report within the designated time frame to ensure that the claim is processed promptly.

Who needs the employee's report of claim?

1. The employee who has experienced an incident or injury and wishes to file a claim with their employer's insurance or workers' compensation provider.
2. The employer or human resources department who needs to document and investigate workplace incidents or injuries, as well as initiate the claims process if necessary.
3. Insurance or workers' compensation providers who require the employee's report of claim to assess the validity of the claim and determine the appropriate course of action.

For pdfFiller’s FAQs

Where do I find employee39s report of claim?

The premium version of pdfFiller gives you access to a huge library of fillable forms (more than 25 million fillable templates). You can download, fill out, print, and sign them all. State-specific employee39s report of claim and other forms will be easy to find in the library. Find the template you need and use advanced editing tools to make it your own.

How do I make edits in employee39s report of claim without leaving Chrome?

Install the pdfFiller Google Chrome Extension to edit employee39s report of claim and other documents straight from Google search results. When reading documents in Chrome, you may edit them. Create fillable PDFs and update existing PDFs using pdfFiller.

Can I create an electronic signature for signing my employee39s report of claim in Gmail?

Upload, type, or draw a signature in Gmail with the help of pdfFiller’s add-on. pdfFiller enables you to eSign your employee39s report of claim and other documents right in your inbox. Register your account in order to save signed documents and your personal signatures.

What is employee39s report of claim?

The employee's report of claim is a document that an employee fills out to report an incident or injury that occurred in the workplace.

Who is required to file employee39s report of claim?

Any employee who experiences an incident or injury in the workplace is required to file an employee's report of claim.

How to fill out employee39s report of claim?

To fill out the employee's report of claim, the employee needs to provide details about the incident or injury, including the date, time, location, description of the event, and any witnesses. The form can usually be obtained from the employer or human resources department and should be completed accurately and honestly.

What is the purpose of employee39s report of claim?

The purpose of the employee's report of claim is to document and report workplace incidents or injuries. It helps facilitate the workers' compensation process and ensures that the employee's rights are protected.

What information must be reported on employee39s report of claim?

The employee's report of claim typically requires the following information to be reported: employee's personal details, date and time of the incident, description of the incident or injury, witnesses' names and contact information, and any medical treatment received.