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Documents You Need to File a Workers' Compensation Claim


    Did you know that when you experience a work-related illness or injury, you might be entitled to workers' compensation? However, in order to file a workers' compensation claim, you will need to first report your injury (or illness) and fill out a few key documents. It is important to note that your claim must be filed in accordance with your state's specific workers' compensation procedures.


    Reporting Your Work Injury


    In practically every state, you will need to immediately report your occupational injury or illness to your employer. In fact, your work-related injury or illness must be reported within your state's time limit. As a general rule of thumb, the sooner you file your claim, the faster you can receive workers' compensation benefits. Make sure that you keep thorough records regarding your injury or illness. These records will be included in your report to your employer.


    You will also need to show proof that your injury is work-related, as well as thorough medical records regarding your treatment. For example, if you need to go to the emergency room for treatment, then you will need to submit the associated medical paperwork to your employer as part of your report and workers' compensation claim. Additional information that should be added to your report, includes:


    • How the accident happened (be as specific as possible).
    • The kind of injury or illness.
    • The date and time of the injury or illness. Once again, it is important that you are as specific as possible regarding the details of your occupational injury or illness.


    Submitting the Official Paperwork


    Once you have notified your employer of your occupational injury or illness, you will receive the official documents and forms that need to be accurately filled out as part of your workers' compensation claim. These forms will then be submitted to your employer's insurance company, as well as the state’s workers’ compensation agency. It is important to note that the number of and type of forms will vary from state to state. Additionally, if you are a federal employee, then you will have to fill out different forms. These forms can be found at the Division of Federal Employees' Compensation.


    As a general rule of thumb, your state will typically require you to fill out the following types of forms:


    • An application for review form. -- This form will give you a chance to clearly state the "who, what, where, when, and why" of your injury or illness.
    • Medical forms. -- These forms will be related to any medical treatments that you have received for your occupational injury or illness.
    • Agreement to compensation. -- This type of form will be provided during the later stages of your workers' compensation claim. The form can be used to clearly state the benefits and compensation that you will receive (if your claim is approved).


    Remember that the type and number of documents that you need to fill out and submit will depend on a) your state, b) the type of injury or illness, and c) your employer's insurance company. For example, in Indiana the following forms could be needed when filing a workers' compensation claim:


    • Application for Review by Full Board - SF 1042.
    • Agreement to Compensation - SF 1043.
    • Report of Attending Physician - SF 2118.
    • Application for Adjustment of Claim for Provider Fee - SF 18487.
    • Agreement to Compensation Between the Dependents of Deceased Employee and Employer - SF 18875.
    • Application for Adjustment of Claim - SF 29109.
    • First Report of Injury - SF 34401.
    • Agreement Between Parties for Lump Sum Payment - SF 34873.
    • Subpoena - SF 34877.
    • Notice for Worker's Compensation and Occupational Diseases Coverage - SF 36097.
    • Report Of Temporary Total Disability (TTD)/Temporary Partial Disability (TPD) Termination/Reduction - SF 38911.
    • Request for Assistance - SF 45442.
    • Application for Worker's Compensation Clearance Certificate (English) - SF 45899.
    • Application for Worker's Compensation Clearance Certificate (Spanish) - SF 55718.
    • Notice of Inability to Determine Liability / Request for Additional Time - SF 48557.
    • Application for Second Injury Fund Benefits - SF 51247.
    • Request for Prosthetic Repair or Replacement - SF 51702.
    • Provider Fee Request for Assistance - SF 52875.
    • Request for Public Record - SF 53811.
    • Employee Waiver of Examination by Personal Physician - SF 53913.
    • Notice of Denial of Benefits - SF 53914.
    • Notice of Suspension of Compensation and/or Benefits - SF 54217.
    • Certification of Insurance Carrier as to Number of Worker's Compensation Policies Written or Renewed - SF 55310.
    • Self-Insurance Forms.
    • 2nd Injury Fund Forms.


    The Bottom Line: A Workers' Compensation Attorney Can Help You Accurately Fill Out the Right Documents


    As seen through the above sections, the number, type, and complexity of documents needed for workers' compensation claims will vary from state to state. The good news is that a workers' compensation attorney can help you to more easily complete the entire claims process. Your trusted attorney can guide you through the entire workers' compensation claim process, and help you to receive the benefits that you deserve for an occupational injury or illness.