Get the free Form 801, Workers' Compensation Claim Form - comptroller tn

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How to fill out form 801 workers compensation

How to fill out form 801 workers compensation:

1. Obtain the form: You can typically find form 801 workers compensation on the website of your state's workers compensation board or department. You may also be able to get a copy from your employer or insurance provider.
2. Read the instructions: Before filling out the form, carefully read through the instructions provided with it. These instructions will guide you through the process and ensure you provide all the necessary information.
3. Personal information: Start by filling in your personal information section of the form. This includes your full name, address, date of birth, and contact details. Make sure to provide accurate information to avoid any delays or issues with your claim.
4. Employer information: Next, you'll need to provide details about your employer. This includes the name of your employer, their address, and their workers compensation insurance carrier, if known.
5. Injury details: In the designated section, describe the details of your workplace injury or illness. Include information such as the date and time of the incident, the location where it occurred, and a detailed description of what happened. Be concise but provide enough information to accurately convey the nature of your injury.
6. Medical treatment: Indicate the medical treatment you have received for your injury or illness. Include the names and addresses of any healthcare providers you have visited, as well as any hospitals or medical facilities where you received treatment.
7. Time off work: Specify the dates you missed work due to your injury or illness. Include both the beginning and end dates of your absence and the total number of days you were unable to work.
8. Sign and date the form: Once you have completed all the necessary sections of the form, sign and date it. Your signature confirms that the information you provided is true and accurate to the best of your knowledge.

Who needs form 801 workers compensation?

Form 801 workers compensation is typically required by employees who have suffered a workplace injury or illness and wish to file a claim for workers compensation benefits. It is essential for individuals seeking compensation for medical expenses, lost wages, and other benefits resulting from a work-related injury. Both full-time and part-time employees may need to complete this form, depending on their jurisdiction's workers compensation laws and regulations. Additionally, employers and insurance providers may also require this form to initiate the claims process and evaluate the eligibility of the injured worker for benefits.

For pdfFiller’s FAQs

What is form 801 workers compensation?

Form 801 workers compensation is a document used to report an on-the-job injury or illness to the employer's workers' compensation insurance carrier.

Who is required to file form 801 workers compensation?

Employers are required to file form 801 workers compensation when an employee suffers an injury or illness on the job.

How to fill out form 801 workers compensation?

Form 801 workers compensation should be filled out by providing details of the injury or illness, including the date and location of the incident, a description of the injury, and any medical treatment received.

What is the purpose of form 801 workers compensation?

The purpose of form 801 workers compensation is to document and report work-related injuries or illnesses in order to provide the necessary compensation and medical benefits to the affected employees.

What information must be reported on form 801 workers compensation?

Information such as the employee's name, contact information, job title, date of injury, and details of the injury or illness must be reported on form 801 workers compensation.

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