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.