WORKER'S COMPENSATION COMMISSION
Department of Labor * Government of Guam
P. O. Box 9970 Tamuning, Guam 96931
Tel: (671) 300-4571/77 Fax: 671-475-6811
WCC File #:
INSTRUCTIONS: This form may be used by the Employee to file a NOTICE of an injury, illness or in the case of death, by Employee's representative. No
benefits need be paid without this notice. Notice shall be given to the Commissioner and to the Employer by delivery or to the last known place of business.
22 GCA 9113. PLEASE PRINT OR TYPE.
** THIS IS NOT A CLAIM **
1. Name of injured Employee, DOB, & SSN: - -
2. Name of Employer & EIN:
3. Employee's address & telephone no: ( )
4. Employer's address:
5. Date & time of alleged injury/illness: 6. Did employee stop work?
If so, date stopped:
7. Employee's occupation:
8. Name of supervisor at time of injury:
9. Place where injury occurred:
10. Is another person not of your employment the cause of the
[ ] YES [ ] NO
11. Will you file suit against the other person?
[ ] YES [ ] NO
12. DESCRIBE IN FULL HOW THE ACCIDENT OCCURRED: Relate the events which resulted in the injury/illness. Tell what the
Employee was doing at the time of the accident. Tell what happened and how it happened. Name any object or substance involved and tell
how they were involved. Give full details on all factors which led or contributed to the accident. Use additional sheets if required and attach
to this report.
13. Effects of the injury (Indicate parts of body affected and how affected).
22 GCA §9132 “Any person who willfully makes any false or misleading statement or representation for the purpose of obtaining any benefit or
payment under this Title, or for the purpose of evading liability for any benefit or payment under this Title, shall be guilty of a misdemeanor.”
14. Name & signature of person completing this notice:
15. Date of this notice:
FOR STATISTICAL PURPOSES ONLY
Please choose ONE ETHNICITY: Please choose ONE CITIZENSHIP:
Yapese Marshallese American
Chuukese Palauan African American
Kosraean Guamanian Japanese
Pohnpeian Filipino Korean
Chinese Other (specify):
Permanent Resident Alien
Form GWC-201: NOTICE of EMPLOYEE'S INJURY/ILLNESS or DEATH (Revised 3/2014)