Worker's Compensation Claim Form

Employee Name *

First Name Last Name

Job Title *

Department *

Address *

Street Address

Street Address Line 2

City State

Zip Code

Phone Number *

Area Code Phone Number

Supervisor *

Supervisor's E-mail *

Shift (If applicable)

Date of Injury/Illness *

Month Day Year

Time of Injury/Illness *

: Hour Minutes AM/PM Option

Accident Cause *

Injury Nature *

Side of Body *

Body Part *

Accident Description *

List direct cause(s). *

List both unsafe actions and unsafe conditions (e.g., improper lifting, lowering, or carrying technique, etc.)

List root (underlying) cause(s). *

e.g., inadequate enforcement of work rules and procedures or lack of proper job procedures

Are you losing time? *

Yes No

Are you on modified duty? *

Yes No

Where did the injury/illness occur? *

Describe the weather conditions *

Did anyone see the accident occur? If yes, who? *

Who did you first report the accident to? *

Please make note of the following information:

Worker's Compensation Insurance Carrier: PMA Management Corp.
Phone Number: (888) 476-2669

Address:
PMA Medical Bills
P.O. Box 5231
Janesville, WI 53547-5231

The HR Office will email you your claim number within 24 hours of your claim submission. If you do not have your claim number prior to seeking medical attention, please provide your physician with our HR contact information - Annie Steve, 315-445-4155, steveam@lemoyne.edu.

Worker's Compensation Claim Form

For Employee's Supervisor to Complete