Get the free NEW Accord Workmen's Compensation Report Form

WORKERS COMPENSATION FIRST REPORT OF INJURY OR ILLNESS EMPLOYER (NAME & ADDRESS INCL ZIP) CARRIER / ADMINISTRATOR CLAIM NUMBER * JURISDICTION * REPORT PURPOSE CODE * JURISDICTION LOG NUMBER * INSURED

How to fill out new accord workmen39s compensation

To fill out the new Accord Workmen's Compensation form, follow these steps:

1. Obtain the form: The new Accord Workmen's Compensation form can usually be obtained from your insurance provider or downloaded from their website.
2. Personal Information: Start by providing your personal information, such as your name, address, contact details, and any other requested information. Ensure that all information is accurate and up to date.
3. Company Information: Fill in the details of your company, including the company name, address, and contact information. This information is necessary to associate the compensation claim with the correct company.
4. Policy Information: Provide details of the Workmen's Compensation policy you have with your insurance provider. This may include the policy number, effective dates, and coverage amounts.
5. Employee Details: Specify the employees for whom the compensation claim is being made. Include their names, job titles, dates of birth, social security numbers, and employment start dates.
6. Incident Details: Describe the nature of the incident or injury that occurred, including the date, time, and location. Provide as much detail as possible to help accurately assess the claim.
7. Witness Statements: If there were any witnesses to the incident, include their statements, contact information, and any other relevant details. Witness statements can serve as valuable evidence in determining the validity of the claim.
8. Medical Treatment: Provide information on the medical treatment received by the injured employee. Include the names of treating physicians or hospitals, dates of treatment, and any other relevant medical information.
9. Supervisor Report: If applicable, include a report from the employee's supervisor or manager regarding the incident. This report should include their observations, any safety measures in place, and any corrective actions taken.
10. Supporting Documents: Attach any supporting documents that may be necessary to substantiate the claim, such as medical reports, police reports, incident reports, or any other relevant documentation.
11. Sign and Submit: Once you have completed all the necessary sections of the form, review it for accuracy and sign it. Make sure to keep a copy of the completed form for your records. Submit the form to your insurance provider, either electronically or through mail, as instructed.

Who needs new Accord Workmen's Compensation?

The new Accord Workmen's Compensation form is typically needed by employers who want to make a claim for compensation on behalf of their employee(s) who have experienced work-related injuries or illnesses. It is essential for employers to complete this form accurately and thoroughly to ensure that the claim is processed efficiently and effectively.

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