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Filing a Workers' Comp Claim
When you are hurt on the job your employer begins the claim process. If you need medical attention your employer must notify its workers’ compensation insurance company of the medical bills. The insurer (your employer's workers' compensation insurance company) will issue you an insurance card, with a claim number, which you will give to your doctor so the medical bills can be sent directly to the insurer. If you don’t get this card promptly after your injury, contact the insurer. Most medical providers will be looking for this number. When you see a doctor or other health-care professional make sure you inform them that you are seeking treatment for a work-related injury. If they accept you as a patient, they are agreeing to bill the insurer for your treatment. The insurer is responsible for the entire bill, there is no co-payment you need to make.

If you are disabled, unable to earn your full wages for a period of five or more calendar days, your employer has to report your incapacity to its insurance company and to the DIA on an Employer's First Report of Injury/Fatality form (Form 101). These five days do not have to be consecutive, and any day you aretotally or partially disabled is counted.

Your employer must furnish this report within seven calendar days, not including Sundays and legal holidays, of your fifth calendar day of incapacity. If you report the injury to your employer after you have already been disabled for five or more days, your employer is obligated to file within seven days of the day you actually reported the injury to them. If your employer does not send this report to the insurer, you should report the injury to the insurance company yourself. Your employer should have displayed in the workplace a poster, with the name and address of its WC insurer, and other information. If your employer does not have this poster up, and will not tell you the name of its insurance company, the DIA’s office of insurance will try to help you.

The insurer must begin to pay you for lost wages or send you a notice of denial that includes its reasons for the denial, within 14 days of receiving the Form 101 from your employer. This means you should start getting a check within three to four weeks after your injury. You will receive compensation for lost wages for any days you are disabled after the first five days. You are not compensated for the first five days of incapacity unless you are disabled for 21 days or more.

The insurer may pay benefits to you for up to 180 days without making a final decision on your case. This is referred to as the "Pay without Prejudice" period. During this initial period the insurermay stop or reduce your payments by giving you seven days written notice of the termination or reduction. They must give the reasons for taking this action. If the insurer continues paying you past this period, they will, in most cases, need permission from you or a judge to stop or reduce your benefits. NOTE: The 180-day "Pay without Prejudice" period can beincreased by the insurer to one year, with your written consent. You should make sure you are aware of all your rights before giving your consent, or signing any other document.

Filing a workers' compensation claim is a complicated and difficult task. If you would like your claim to be reviewed by an attorney, complete the form below for a free evaluation.

Free Filing a Workers Comp Claim Consultation

Title:
First Name:	*
Middle Name:
Last Name:	*
Home Phone:	*
Cell Phone:
Work Phone:
Email Address:
Address:	*
City:	*
State, Zip:	* *
What is the best way to reach you? Please provide the best place, time and method for contacting you.

Injured Person Information:

Date of Birth / Age: (ex. mm/dd/yyyy or 54)
Were you injured?	Yes No
If not, who are you inquiring on behalf of?

If you are NOT inquiring on your own behalf,
what is your relationship to the injured person?

Is the person deceased?

Yes No

If deceased, what is the cause of death
as stated on the death certificate:

Date of Death: (ex. mm/dd/yyyy)
Was an autopsy performed?	Yes No
If not deceased, does the injury prevent you or the victim from working?	Yes No

If yes, when did you/victim stop working?
What is the approximate lost wages due to the injury?

Accident / Injury Information:

Date of Accident:	*
City where accident occured:	*
State where accident occured:	*

Please briefly explain the incident that caused the injury:
Who do you believe was at fault in causing the injury, and what do you believe they did wrong?
Describe the injuries in detail:

Do you believe the injuries are permanent?

Yes No

Case Description*
Please explain exactly what happened, trying to state
as thoroughly as possible who you believe was responsible
and why you believe that person was negligent:

Please explain the full extent of the victims injuries:

Comments / Additional Information
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