Use this as a private worksheet
Keep evidence about a potentially responsible non-employer separate from the workers’ compensation claim. This is not an official agency or court form.
Third-party file
- ☐ Person/company involved: ______________________________
- ☐ Incident report: ______________________________
- ☐ Photos/video: ______________________________
- ☐ Witnesses: ______________________________
- ☐ Insurance information: ______________________________
- ☐ Property/equipment involved: ______________________________
Workers comp file
- ☐ Employer notice: ______________________________
- ☐ Claim number: ______________________________
- ☐ Medical records: ______________________________
- ☐ Benefit payments: ______________________________
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.