PROMEDICAL - Employer WC Form

Please complete the requested information below so we can help process your employee's medical claims as quickly as possible. We will use this information to bill your Workers' Compensation insurance carrier. (* = required entry)

Name of Employee who was treated for this Accident*

First NameLast Name

Our File Number

Example: 1234567 (Leave blank if not known or not assigned)

Name of Medical Provider where Employee was treated*

Example: ABC Hospital

Name of your Business*

Where the patient was employee

Contact Person at Business*

Used if we have any questions

Your Business Address

Street Address

CityState

Zip Code

Business Contact Email Address*

example@example.com

Business Contact Telephone Number

Format: (000) 000-0000.

Did the Employee notify you of this work related accident?*

YesNoThis was not a work related injuryThe employee did not work for this business at the time of the accident

Signature of Authorized Employer - Not Work Related - Please be advised that on the date of the above-referenced medical services for the employee, the employee was not injured in a work-related accident for this business. Please contact the employee directly or bill their Health Insurance company.

Signature of Authorized Employer - Not Employed at Time of Accident - Please be advised that on the date of the above-referenced medical services for the employee, the employee was not an employee for this business. Please contact the employee directly or bill their Health Insurance company.

Date of Accident/Injury

Date

Was your Workers Compensation Insurance company notified of this accident?*

YesNoNot Sure

Your Worker's Compensation Insurance Company Name (at the time of the accident)*

Workers' Compensation Insurance at the time of the accident, e.g. Liberty Mutual

Your Worker's Compensation Insurance Policy Number

Workers' Compensation Insurance at the time of the accident, e.g. Liberty Mutual

Policy Effective Date

Date

Workers Comp Ins Claim Number

Claim number assigned for this injury

Workers' Compensation Insurance Address

Street Address

CityState

Zip Code

Workers Comp Ins Adjuster Name

Workers Comp Ins Telephone Number

Format: (000) 000-0000.

Any additional comments regarding this claim: