Workers Compensation Claim Form


2010 W. Swain Road Stockton, CA 95207

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Workers' Compensation Claim Form

Name of Injured Employee A value is required.

Date of Injury (mm/dd/yy) A value is required.Invalid format. Time of Injury (hh:mm am/pm)
A value is required. Time employee started shift A value is required.

Address/Location injury occurred
A value is required.

Date Employer First Knew of Injury
(mm/dd/yy)
A value is required. Date claim form was provided to employee
(mm/dd/yy)
A value is required.

Please describe how the injury / accident occurred
A value is required.

Part of body effected / injured
A value is required.

Will or did the employee visit a doctor? A value is required. (yes or no) If "yes" enter name of doctor

Please list any witnesses to the injury / accident A value is required.

Name of person submitting this form
A value is required.

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