Workers compensation claim form
An employee reports an injury to you first. This form captures what happened — where, when, what was injured — so HR has it on file and can start the claim process with your insurer. The form is the internal record-keeping tool. Filing the claim with your workers' comp insurance or your state agency is what your HR team does afterward, using the information from this form plus your own verification.
The form beside this text is live. Fill it in and submit it — it validates exactly as it would for a real respondent, and saves nothing.
Structured date and time, not "last week sometime"
Date and time fields capture the exact moment, which matters for your claim and for the investigation. "Tuesday around 10" is not precise enough for an incident report.
Body part as a dropdown for consistency
You can report and count injuries by body part across your workforce. Free text like "knee area" and "upper knee" both go on different rows. A dropdown means all knee injuries land in the same category.
No card required.
Workers Compensation Claim Form
Live previewHow to build this form
5 steps in the editor. Nothing here needs a paid plan.
- Add text fields for the employee name and current position, plus email and phone for your HR team to reach them.
- Add date and time fields for when the injury happened. The exact moment matters for the investigation.
- Add a text field for the location where the injury occurred — job site, warehouse, office, etc.
- Add a long text field for a detailed description of how the injury happened, and a dropdown for the body part affected.
- Add optional fields for witness names and immediate action taken. Route responses to HR via email so your team can start the workers' comp process.
Fields in this form
11 fields, using 6 of the 19 field types available.
| Question | Field type | Required |
|---|---|---|
| Employee name | Short text | Yes |
| Employee ID or number | Short text | Optional |
| Position or job title | Short text | Yes |
| Employee phone | Phone | Optional |
| Date of injury | Date | Yes |
| Time of injury | Time | Yes |
| Where did the injury occur? | Short text | Yes |
| Body part affected | Dropdown | Yes |
| Describe how the injury happened | Long text | Yes |
| Witness name (optional) | Short text | Optional |
| Immediate action taken | Long text | Optional |
What goes wrong with this form
Specific to a workers compensation claim form, not general advice about forms.
Collecting the injury report and nothing else
Capture the exact time, not just the date. If an employee was injured at 9 a.m., working what shift, during what task — those details matter for your investigation and your claim. A text field that says "Tuesday" is incomplete.
Treating the form as the legal filing
This is internal record-keeping. Your HR team still has to review it, verify the injury, and file the formal claim with your workers' comp insurance or your state agency. The form is the first step, not the only step. You remain responsible for the filing.
Making it optional for the employee to report
An injury that is not reported in this form is not on your record. Your team cannot file a claim for what you did not know happened. Encourage reporting immediately, and remind supervisors that documenting an injury — even one the employee says is minor — is better than finding out later that it got worse.
Questions about this form
What information does a workers' compensation claim form collect?
Employee name, date and time of injury, location, description of what happened, affected body part, and optional witness information. This gives your HR team the details they need to start your workers' compensation process with your insurer or state agency.
Does this form file a claim with my insurer?
No. This is an internal intake form. A person on your HR team reviews the form, verifies the injury against your records, and then files the claim with your insurer or state agency using this information plus your own company documentation. The form is where the process starts, not where it ends.
What should the employee do if they are too injured to fill out the form?
A supervisor or HR representative can fill it out based on what the employee tells them. The goal is to get the information on record. If the employee is unable to communicate, the supervisor documents what they observed and notes that details came from witness observation rather than the employee directly.