Employees Claim For Compensation For Disability

GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES DEPARTMENT OF LABOR 314 King Street - Frederiksted St. Croix, VI 00840 Phone: (340) 692-9390 Fax (340) 772-3365 P. O. Box 302608 St. Thomas, VI 00803-2608 Phone: (340) 776-3700 Fax (340) 774-6801 Workers' Compensation Administration EMPLOYEE'S CLAIM FOR COMPENSATION FOR DISABILITY INSTRUCTIONS: Every question on this blank must be answered. Write "None" in spaces which are not applicable to your case. Write in ink or on typewriter. The claim must be filed within 60 days after the injury. The claim must be sworn to in the presence of a Notary Public, or before the District Director of Workers' Compensation. NAME OF INJURED EMPLOYEE: (Please Print) I hereby make claim for compensation for the injury and resulting disability described below due to an accident arising out of and in the course of my employment with Name of Employer of The said injury was not caused by willful misconduct on my part or by my willful intention to injure or kill myself or another, or by my intoxication. INJURY: Date of Accident: Location of Accident: If away from employer's premises, explain briefly duty which carried you there Describe how accident occurred: Description of injury (indicate member of body injured) Is it temporary or permanent? Other pertinent Information DISABILITY RESULTING FROM INJURY: Date disability began: Partial Are you now disabled? Date disability ceased: Partial Total Total If disability was intermittent, state various periods of disability Date returned to work; On part pay: If you have not returned to work though not now disabled, explain On full pay: EARNINGS: Were you paid in full for the day the accident occurred? If your wages continued beyond the date of accident, what was the last day for which paid? What was the first day for which you received pay upon return to work? If your disability was partial or intermittent, give, in detail, your earnings (rate and amount) if any, and the various periods (dates) for which you have been paid: Wages or average earnings before injury: Per Hour Per Day Per Week Were you a full-time or an intermittent worker? explain: If irregular or overtime earnings involved in above, Wages or average earnings upon return to work: Per Hour: If these differ from the earnings before injury, explain: REGARDING THE INJURED EMPLOYEE: Sex How long have you worked for the employer indicated above? Were you doing your regular work when injured? Age Per Day: Per Week: Married or Single In what occupation? If not, what work? REGARDING MEDICAL ATTENDANCE: What physician attended you? Where? Date Discharged: ACKNOWLEDGED, SUBSCRIBED AND SWORN TO BEFORE ME THIS _______ __DAY_____________________________________ 20________ Address: or (Signature if person filing claim on behalf of injured employee) Relationship to injured employee, If any _________________________________________________________________________________ Notary Public Mailing Address: If hospitalized: Name of Hospital SIGNED, This day of 20 Date entered at Signature of Injured Employee Telephone Number Form #: _____________________________________________ American LegalNet, Inc. www.FormsWorkflow.com