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DATE (MM/DD/YYY) WORKERS COMPENSATION APPLICATION AGENCY NAME AND ADDRESS COMPANY: UNDERWRITER: APPLICANT NAME: OFFICE PHONE: MOBILE PHONE: MAILING ADDRESS (including ZIP + 4 or Canadian Postal Code)
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How to fill out workers compensation application 130

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How to fill out workers compensation application 130:

01
Start by providing your personal information such as your name, address, phone number, and social security number.
02
Indicate the date of the injury or illness that you are filing a workers compensation claim for.
03
Describe the details of the incident, including the location, time, and cause of the injury or illness. Be as specific as possible.
04
Provide information about your employer, such as the company name, address, and contact details.
05
Include details about your job position and duties at the time of the incident.
06
If you received medical treatment for your injury or illness, provide the name and address of the healthcare provider.
07
Indicate whether you have previously filed a workers compensation claim or have any other related legal proceedings.
08
Attach any supporting documents such as medical reports, accident reports, or witness statements to strengthen your claim.
09
Review your application thoroughly to ensure all the information provided is accurate and complete.

Who needs workers compensation application 130:

01
Employees who have sustained an injury or illness at work that they believe is eligible for workers compensation benefits.
02
Individuals who seek compensation for medical treatment, lost wages, or potential disability resulting from a work-related incident.
03
Workers who want to file a formal claim with their employer's insurance company or the appropriate workers compensation board.
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Workers compensation application 130 is a form used by employers to report work-related injuries and illnesses to their insurance company.
Employers are required to file workers compensation application 130 to report any work-related injuries and illnesses.
Workers compensation application 130 can be filled out by providing details of the injured employee, the nature of the injury, and the circumstances of the incident.
The purpose of workers compensation application 130 is to ensure that injured employees receive proper medical care and compensation for their work-related injuries.
Information such as the injured employee's name, date of injury, description of injury, and witness statements must be reported on workers compensation application 130.
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