Employer Name*
    Employer Address*
    City*
    State*
    Zip*
    Is this a public school system?
    What portion of employee’s wages are funded by the local government? Percentage calculated based on time period of 52 weeks prior to date of accident (Local Funding amount divided by Total Wages)
    Is the accident address different from employer address?
    Accident Location Name (if different from above)
    Accident Address

    City*
    State*
    Zip*
    Is this accident location employer's premises?*
    Policy Number
    Employer Contact Name*
    Employer Contact Email Address*
    Employer Contact Phone*


    Step 2: Claimant Information

    Last Name*
    First Name*
    Middle Name
    Claimant’s Preferred Language
    Address*

    City*
    State*
    Zip*
    County*
    Home Phone
    Work Phone
    Date of Birth (MM/DD/YYYY)*
    Social Security Number (Digits only, No dashes)*
    Gender*
    Smoker*
    Marital Status
    Number of Dependents

    Height

    Feet
    Inches
    Weight (approximate in lbs.)
    How satisfied is claimant with their job?*


    Step 3: Accident Information

    Date of Injury*

    Date the Employee reported injury to Employer*

    Time of Injury*
    Did more than one day pass between date of injury and date injury was reported to the Employer?
    Please indicate why there was a delay in reporting the injury to the employer
    To whom was the claim reported?*
    Accident Description including body parts and type of injury *
    Are there any witnesses?*
    Please list all witnesses below:

    Witness Name*
    Witness Phone*
    Please attach witness statement:

    Please attach photo or video of accident scene


    Step 4: Employment Information

    Supervisor Name *
    Supervisor Phone Number*
    Describe claimant's occupation and job duties:*
    Attach detailed job description:
    Class Code
    Date of Hire
    Was a Post-Offer Medical Questionnaire completed?*
    Please Attach Questionnaire:
    Employment Status*
    Number days worked per week*
    Number of hours worked per day*
    Shift
    Is Employee paid salary or by the hour?*
    What is their hourly rate?*
    What is their yearly salary?*


    Step 5: Subrogation

    Are there any other contributing parties that may have caused the accident?*
    Describe the potentially responsible party (name, address, phone number, email)
    Insurance information of potentially responsible party (Insurance company name, address, phone, email)
    Do you have a police report?*
    Upload Police Report:


    Step 6: Medical Treatment

    Was a Post-Accident Drug Screen completed?*
    Results of Drug Screening *
    Name and Address of location where drug screening was completed.*
    Type of treatment received:*
    Facility Name
    Provider/Treating Physician
    Provider Address
    Phone
    Date Treated
    Next follow-up appointment
    Referrals
    Was this an employer authorized visit?*
    Upload Medical Records Report:
    Upload Doctor's Note:


    Step 7: Return to Work Information

    Was the employee paid for the date of injury in full? *
    Do you anticipate missed time from work due to this injury? *
    Has the employee returned to work?
    When did the employee last work?*
    Was the employee paid in full for the date of injury?*
    Has the employee provided a work note?

    What date did the employee return to work?
    What is their work status?
    Has the employee provided a work note?
    When do you expect the employee to return to work?
    Has the employee provided a work note?
    Employee note:
    Is this employee's salary being continued in full?*
    Last day wages will be paid instead of workers’ compensation


    Step 8: Additional Questions

    Do you have any reason to question the injury or accident?*
    Please Explain Why:*
    Do you know of any prior or ongoing medical conditions?*
    Please Explain:*
    Has the employee ever injured this body part in the past?*
    Please Explain:*
    Does the employee have concurrent employment?*
    Please Explain:*
    Was there a safety violation?*
    Please Explain:*
    Has the employee filed any other workers' compensation claims?*
    Please Explain:*
    Additional Comments:
    Please upload any additional attachments not already included in the claim report:

    Please review the claim report details entered. If you need to make an edit to any of the sections, please do so by clicking the edit button. Please do not click the browser back button. Once you’ve completed your review of the claim report details, click the “Send” button at the bottom of this page to submit the claim to Prescient National.

    Get Started: Employer Information

    Employer Name :
    Employer Address :
    city :
    state :
    zip :
    Is this a public school system? :
    What portion of the employee's wages are funded by the local government :

    Is the accident address different from employer address :
    Accident Location Name :
    Accident Address :
    Accident city :
    Accident state :
    Accident zip :
    Is this accident location employer's premises?
    Policy Number :
    Employer Contact Name :
    Employer Contact Email Address :
    Employer Contact Phone :

    Edit

    Step 2: Claimant Information

    Last name :
    First name :
    Mid name :
    Claimant’s Preferred Language :
    Address :
    Claimant city :
    Claimant state:
    Claimant zip:
    Claimant County:
    Home Phone :
    Work Phone :
    Date of Birth :
    Social Security Number :
    gender :
    Smoker :
    Marital Status :
    Number of Dependents :
    Height : Feet Inches
    Weight (approximate in lbs.):
    How satisfied is claimant with their job?

    Edit

    Step 3: Accident Information

    Date of Injury :
    Time of Injury :
    Date the Employee reported injury to Employer :
    Did more than one day pass between date of injury and date injury was reported to the Employ :
    Please indicate why there was a delay in reporting the injury to the employer :
    To whom was the claim reported?

    Accident Description including body parts and type of injury :

    Are there any witnesses?

    Edit

    Step 4: Employment Information

    Supervisor Name :
    Supervisor Phone Number :
    Describe Claimant's Occupation and Job Duties:
    Attach Detailed Job Description:
    Class Code :
    Date of Hire :
    Was a Post-Offer Medical Questionnaire completed?
    Please attach questionnaire:
    Employment status :
    Number Days Worked Per Week :
    Number Hours Worked Per Day :
    Shift :
    Is Employee Paid Salary or by The Hour?
    What is Their Hourly Rate?
    What is Their Yearly Salary?

    Edit

    Step 5: Subrogation

    Are there any other contributing parties that may have caused the accident?

    Describe the potentially responsible party :
    Insurance information of potentially responsible party :
    Do you have a police report?
    Upload police report:

    Edit

    Step 6: Medical Treatment

    Was a Post-Accident Drug Screen completed?
    Results of drug screening :
    Name and Address of location where drug screening was completed. :

    Type of treatment received :

    Edit

    Step 7: Return to Work Information

    Was the employee paid for the date of injury in full?
    Do you anticipate missed time from work due to this injury?
    Is this employee's salary being continued in full?

    When did the employee last work? :

    When do you expect the employee to return to work?

    Has the employee provided a work note?

    Has the employee returned to work?
    What date did the employee return to work?
    What is their work status?
    Was the employee paid in full for the date of injury?
    Last day wages will be paid instead of workers’ compensation:

    Edit

    Step 8: Additional Questions

    Do you have any reason to question the injury or accident?
    Please explain why:

    Do you know of any prior or ongoing medical conditions?
    Please explain why:

    Has the employee ever injured this body part in the past?
    Please explain why:

    Does the employee have concurrent employment?
    Please explain why:

    Was there a safety violation?
    Please explain why:

    Has the employee filed any other workers' compensation claims?
    Please explain why:

    Additional Comments:

    Edit

    Please PRINT this page before submitting the claim to Prescient National for a detailed claim submission record.

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