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Report FormEmployers Liability Incident Notification Form Please complete Policyholder, Event and Property Sections. Only complete the relevant section(s) of Details of ClaimPolicyholder Policyholders

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How to fill out work injury benefit claim

01

Step 1: Obtain the work injury benefit claim form from your employer or from the relevant government department.

02

Step 2: Fill in your personal details, such as your name, address, and contact information, in the designated fields of the form.

03

Step 3: Provide information about your workplace, including the name and address of your employer, as well as details of any witnesses to the injury.

04

Step 4: Describe the injury or accident in detail, including the date, time, and location it occurred, as well as the specific circumstances surrounding it.

05

Step 5: Provide details of any medical treatment you have received for the injury, including the names of healthcare professionals and any medications or therapies prescribed.

06

Step 6: Attach any relevant supporting documents, such as medical reports, hospital bills, or witness statements, as evidence of the injury or accident.

07

Step 7: Review the completed form to ensure all information provided is accurate and complete.

08

Step 8: Sign and date the form to certify the accuracy of the information provided.

09

Step 9: Submit the filled-out work injury benefit claim form to your employer or the relevant government department, as instructed.

Who needs work injury benefit claim?

01

Work injury benefit claim is needed by employees who have suffered an injury or accident while performing their job duties.

02

It is also required for individuals who wish to seek compensation or benefits for medical expenses, lost wages, or disability resulting from a work-related injury.

03

Both full-time and part-time employees may be eligible to file a work injury benefit claim, depending on their employment status and the specific laws or regulations in their jurisdiction.

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