Sierra Oak Insurance Services Inc.

Workers Comp Claim Form

Name:
Email:
Has this claim previously been turned directly into your Workers Compensation carrier?		Yes No
Each Workers Compensation Carrier requires that their individual in house forms are completed. Have you previously submitted these forms to your carrier?		Yes No
If no do you need us to supply you with the requested forms?		Yes No
Employees Name:
Employees SSN:
Employees Address:
Employees Phone:
Employees Date Of Hire:
Employees Date Of Birth:
Date and Time of Injury:
		Description of Injury: Body part:
Employees Wage:		Employee Job Description:
Employees Class Code:
Time Employee Started work:
Name, address and phone number of the Medical Provider:
Supervisor Info:		Name: Contact Number: Should claims adjustor contact the supervisor regarding claim? Yes No If no, name and number of who should be contacted?
Job location:
Federal Employee ID Number:
Unemployment ID Number: