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Workers Compensation Form
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(571) 489-6600
Workers Compensation Form
Employer
Employer’s Legal Name
Federal Employer Identification Number (FEIN)
Employer’s Mailing Address
Street Address
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Armed Forces Americas
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State
ZIP Code
Name/FEIN of Entity on Policy
Nature of Business
Name and Address of Insurer or Self-Insurer for this Claim
Policy Number
Time and Place of Accident
Location where accident occurred
Date of Injury
MM slash DD slash YYYY
Hour of Injury
:
Hours
Minutes
AM
PM
AM/PM
Date injury or illness reported
MM slash DD slash YYYY
If fatal, give date of death
MM slash DD slash YYYY
If fatal, give number of dependent children
If fatal, give marital status
Single
Married
Divorced
Widowed
Injured Worker
Name of Injured Worker
First
Last
Phone Number
Injured Worker ID Number
Injured Worker’s mailing address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Type of ID
Social Security No.
Employment Visa
Green Card
Passport No.
Unknown
Occupation at time of injury or illness
Date of birth
MM slash DD slash YYYY
Sex
Male
Female
Nature and Cause of Accident
Machine, tool, or object causing injury or illness
Describe fully how injury or illness occurred
Describe nature of injury, occupational disease, or illness, including body parts affected
Name
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