Get the free 440-801 - Workers Compensation Claim Form. Oregon Workers Compensation

Insert self insured employer and insurer name, address, phone number, and Benchmark Insurance Company service company, if any. C/o: Benchmark Administrators LLC PO Box 12792 Workers compensation claim

How to fill out 440-801 - workers compensation

How to fill out 440-801 - workers compensation

1. Gather all necessary information, including details about the injured worker, the incident that caused the injury, and any medical treatment received.
2. Fill out the employee's personal information, such as name, address, phone number, and social security number.
3. Provide details about the employer, including the company name, address, and contact information.
4. Describe the injury in detail, including the date, time, and location of the incident, as well as the specific body part(s) affected.
5. Include information about any witnesses to the incident, if applicable.
6. Fill out the medical treatment section, including the dates of treatment, the names of healthcare providers, and the specific treatments or procedures performed.
7. Include any additional information or documentation that is required by your state's workers' compensation agency.
8. Review the completed form for accuracy and completeness before submission.
9. Submit the filled-out form to the appropriate workers' compensation agency within the specified timeframe.
10. Keep a copy of the completed form and any supporting documents for your records.

Who needs 440-801 - workers compensation?

1. Any employer who has employees covered by workers' compensation insurance is required to fill out and submit form 440-801.
2. In addition, any worker who sustains an occupational injury or illness and wishes to file a workers' compensation claim will need to provide the necessary information on this form.
3. The form is used to report the details of the incident and the resulting injury or illness, and to initiate the workers' compensation claims process.

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What is 440-801 - workers compensation?

440-801 is a form used to report workers compensation claims and is required by the state.

Who is required to file 440-801 - workers compensation?

Employers are required to file 440-801 for employees who have been injured on the job.

How to fill out 440-801 - workers compensation?

To fill out 440-801, employers must provide details of the injury, treatment received, and other relevant information.

What is the purpose of 440-801 - workers compensation?

The purpose of 440-801 is to ensure that injured employees receive the compensation they are entitled to and to track workplace injuries.

What information must be reported on 440-801 - workers compensation?

Information such as employee details, injury details, treatment received, and any other relevant information must be reported on 440-801.