ARM-Capacity Workers Compensation Claim

HEADQUARTERS
90 Broad Street, Suite 1503
New York, NY 10004
Tel: 646.459.2400
TF: 888.276.6369
Fax: 212.937.3923

Workers Compensation - First Report of Injury or Illness

The following information is required to submit a workers compensation claim. All information must be completed. Should you require assistance to complete this form, please contact your service representative.

INSURED (how the policy is listed)

Name:

Address:

City State ZIP

CONTACT (insured contact information - i.e. owner, facility manager, etc.)

Name:

Home Phone:

Business Phone:

Cell Phone:

Email:

EMPLOYEE / WAGE INFORMATION

Name:

Address:

City State ZIP

Date of Birth # Dependents     Sex

      Male  Female

Social Security #   Martial Status

Single/Divorced   Married   Seperated   Unknown

Date Hired   State of Hire



Occupation / Job Title   Employment Status



Salary / Rate   PER

Per Day   Per Week   Per Month   Other

Avg. Weekly Wages   # Days Worked/Week



Full Pay Day of Injury?       Did Salary Continue?

Yes    No          Yes    No

OCCURENCE / TREATMENT INFORMATION

Date of Occurrence (mm/dd/yyyy)

Time of Occurrence am  pm

Date Last Worked (mm/dd/yyyy)

Date Disability Began (mm/dd/yyyy)

Date Employer Notified (mm/dd/yyyy)

Date Returned To Work (mm/dd/yyyy)

If Fatal, Date of Death (mm/dd/yyyy)

Describe Injury or Illness:

Part/s of Body Affected:

Department or Location Occurred:

List Equipment, Materials or Chemicals Used When Occurred:

Specific Activity Employee Was Engaged in or Exposed to (eg. cutting metal):

Work Process Employee was Engaged In (eg. building maintenance):

How Injury Occurred. Describe Sequence of Events Including
Objects or Substances That Injured the Employee or Made Him Ill:

Initial Treatment:

PHYSICIAN / HEALTH CARE PROVIDER INFORMATION

Name:

Address:

City   State   ZIP



HOSPITAL INFORMATION

Name:

Address:

City   State   ZIP



WITNESS INFORMATION

Witness 1 Name:

Phone Number:
Witness 2 Name:

Phone Number:

IMPORTANT:
In addition to submitting this form,
you MUST send any and all additional information including:
- Police Reports
- Hospital Reports
- Internal Incident Reports
You may also print and fax this form for processing to:
212.937.3923