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 :
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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?
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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?
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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?
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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:
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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 :
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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:
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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:
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