SECTION 1 -  Completion of this section is required

Claim number

Employee’s (First name)

(Last name)

Social Security number*

Date of birth

Gender

Marital status

Employee’s telephone number

Employee’s physical address (Street address)

City

State

ZIP code

Employee’s mailing address, if different than physical address (Street address, PO Box number)

City

State

ZIP code

Date of injury

Time of injury

Nature of injury or illness (broken left leg, carpal tunnel left wrist, etc.)

Body parts injured (Example: 2^nd/middle finger, shoulder, ankle, etc.)

How did the injury happen?

Has this claim been filed in another state?           If yes, which state?

Where did the injury happen? (City)

(County)

(State)

Treating doctor’s name

Date of first treatment

Clinic/hospital name

Emergency Room Visit

Clinic/hospital mailing address (Street address, PO Box number)

Clinic/hospital telephone number

City

State

ZIP Code

Employer’s name

Employer’s telephone number

Employer’s mailing address

City

State

ZIP code

What is the Employee’s job?

Date hired (Month)

(Year)

Last day worked in North Dakota prior to injury

SECTION 2 -  Employee completion

Date employer notified

Person you notified

Before this injury, have you had any problems, injuries, or treatment to the injured body parts? 

Have you missed or will you miss 5 or more consecutive days of work due to the injury? OR  Has a doctor taken you off work for 5 or more consecutive days?    

Witness to the injury (First name)

(Last name)

Telephone number

SECTION 3 -  Release of information/fraud warning/signature

Release of information

I understand and agree that North Dakota law determines all my rights and obligations to and from WSI. I authorize any medical provider or facility, any insurance company, including employees’ compensation relating to work injuries, any law enforcement or military agency, any government benefit agency including the Social Security Administration, and any educational agency or institution to release to WSI, its agents and attorneys, any and all information or records, including all prior records as well as those pertaining to mental health, alcohol, or drug abuse, and HIV/AIDS/AIDS-related illness. I authorize healthcare providers to respond to WSI regarding my injury, including request for conclusions and opinions not otherwise contained within existing medical records. In addition, I authorize any education agency or institution to release to WSI any and all “educational records” as defined by 20 U.S.S 21 Sec. 1232g. This authorization continues while I have any claim open or pending before WSI. WSI is exempt from HIPAA regulations. I authorize WSI to release any information or records about my claim to third parties or their insurers for the purpose of resolving claims against third parties. I authorize the release of any medical information related to my claim to my employer. If you agree, please enter "yes" in the box to the right.   

Fraud warning

Any person claiming benefits or compensation from WSI who files a false claim, or makes a false statement, or fails to notify WSI as to the receipt of income or an increase in income from employment, in connection with any claim or application for employees’ compensation benefits will forfeit any future benefits and may be guilty of a felony which is punishable by imprisonment, substantial fines, or both. These criminal penalties are applicable to all persons dealing with WSI, including injured employees, employers, medical providers, and attorneys. To verify that you have read the Fraud Warning, please type the word "yes" in the box to the right.   

Signature

By signing this form, I acknowledge that I have read and understand the release of information and fraud warning. I understand that falsifying this claim or making a false statement regarding this claim may be a felony, punishable by substantial fines and imprisonment. I authorize the release of information and agree that statements in this form are true and accurate.

Employee’s signature

Date signed

In addition to myself, I authorize WSI to release information on my claim to:

First Name

Last name

Relationship

If you are not the injured employee or the employer, but you are completeting this form on behalf of the injured employee, please enter your name and indicate your relationship to the injured employee:

Name

Relationship

SECTION 4 -  Employer completion

Employer’s account number

Rate class

Is employee a corporate officer, owner, or family member?

Employer’s name

Mailing address (Street address, PO Box number)

City

State

ZIP code

Has the employee missed or will they miss 5 or more consecutive days of work due to the injury? OR  Has a doctor taken the employee off work for 5 or more consecutive days?   

Date employer notified

Person notified

Before this injury, are you aware of the employee having any problems, injuries, or treatment to the injured body part?  

Do you have a Designated

Medical Provider (DMP)?

Did the employee add another medical provider?  

If yes, which provider?      

Do you question this claim?

If yes, please explain in section 5.

Employer’s signature

Title

Date signed

SECTION 5 -  Additional information or comments