INJRPT
Revised 11/11
Claim Number:
CAUSE OF ACCIDENT
JOB DESCRIPTION
INJURED WORKER'S DETAILED JOB TITLE AT TIME OF INJURY. (For example: Civil Engineer, not just Engineer; RN or LPN, not just Nurse; Custodian or General Repairs, not just Maintenance)
WHAT WERE THE TYPICAL DUTIES OF THE INJURED WORKER'S JOB AT THE TIME OF INJURY? (For example: operating heavy equipment, mopping floor, hanging drywall, welding, doing data entry)
WHAT HAPPENED? Tell us how the injury occurred. Examples: "When ladder slipped on wet floor, employee fell 20 feet:; "Employee was sprayed with chlorine when gasket broke during replacement".
WHAT OBJECT OR SUBSTANCE DIRECTLY HARMED THE EMPLOYEE? Examples: "concrete floor"; "chlorine", "radial arm saw". If this question does not apply to the incident, leave it blank.
WHAT WAS THE EMPLOYEE DOING JUST BEFORE THE INCIDENT OCCURED? Describe the activity as well as the tools, equipment, or material the employee was using. Be specific. Examples: "climbing a
ladder while carrying roofing material", "spraying chlorine from hand sprayer", "daily computer key-entry".
WAGE INFORMATION
EMPLOYEE PAID
HOUR DAY WEEK MONTH YEAR BI-WEEKLY SEMI-MONTHLY OTHER
IF HOURLY, WHAT IS THE RATE PER HOUR?
IF NOT PAID HOURLY, WHAT IS THE EMPLOYEE'S PAY RATE HOURS WORKED PER DAY NUMBER OF DAYS WORKED PER WEEK
IS EMPLOYEE AUTHORIZED OVERTIME?
YES NO
NUMBER OF OVERTIME HOURS WORKED
EMPLOYEE PAID FOR THE DATE OF ACCIDENT?
YES NO
DOES THE EMPLOYEE HAVE MORE THAN ONE JOB? IF SO, STATE NAME OF EMPLOYER PROVIDE PHONE NUMBER OF THE ADDITIONAL EMPLOYER
Employee Release: I authorize the Division of Workers’ Compensation to disclose and or obtain information about my case to or from other state agencies;
insurers, group health plans, third party administrators, health maintenance organizations or Medicare and Medicaid service centers. The information that may be
released or obtained includes: my name, my social security number, the medical services I received and the dates of those services, the amounts charged by
health care providers for my medical services, and the amount of benefits paid. This information may be needed to ensure that benefit payment are not
duplicated. The information given by me herein is true and correct. I agree this release shall remain in full effect until revoked by me in writing. Photocopies of
this authorization shall be given the same effect as the original. I further acknowledge that misrepresentation or fraud can lead to a civil action and/or criminal
prosecution.
EMPLOYEE SIGNATURE OR EMPLOYEE'S REPRESENTATIVE TODAY'S DATE RELATIONSHIP TO EMPLOYEE
PRINT EMPLOYEE OR REPRESENTATIVE NAME
EMPLOYEE
SSN#
If you are a Medicare Beneficiary, you are required to provide your HICN assigned by the Social Security Administration:
EMPLOYER / SUPERVISORY SIGNATURE DATE
TITLEPRINT EMPLOYER / SUPERVISOR NAME
Yes No Unsure
Yes No
Drug or alcohol test performed on date of injury?
Do you belive this injury or condition is work-related? If No, please attach letter of explanation stating the disputed facts.
Employer Certification: I am an authorized agent of the employer. The information given by me herein is true and correct. I further
acknowledge that misrepresentation or fraud can lead to a civil action or criminal prosecution.
WORK COMP
EMPLOYER #
BUSINESS
NAME
PHONE #:
MAIL ORIGINAL TO:
DO NOT WRITE IN THIS AREA
IMPORTANT: For General information
visit www.wyomingworkforce.org or
phone (307) 777-7441
