Use this as a private worksheet
Organize threshold coverage facts before relying on a state-only workers’ compensation guide. This is not an official agency or court form.
Coverage facts
- ☐ Employer: ______________________________
- ☐ Work location: ______________________________
- ☐ Job duties/status: ______________________________
- ☐ Contract/project if relevant: ______________________________
- ☐ Incident/exposure record: ______________________________
- ☐ Federal program correspondence: ______________________________
Privacy reminder
Keep sensitive medical, wage, claim-number, and employment information private. Share it only with appropriate official agencies, licensed professionals, insurers, treating providers, or other people who legitimately need it for the claim.
Use the worksheet with the source records
- Enter dates from the notice, medical record, payment record, or message instead of memory.
- Leave an item blank when it is unknown; do not guess to complete the page.
- Keep a private copy and update it after a new notice, appointment, payment, or work-status change.
- Bring the worksheet and the supporting documents to an agency call or lawyer consultation.