PCIS - Enter Wage and Employment Information

Worker Wage and Employment Information

Note: Please send any Supervisor or witness statements and/or Report of Accident you have on file to [email protected]

Fields marked with * are required

Claim Information

Claimant’s Full Name*

Claim Number*

Employer Name*

Account/Policy No. claim should be assigned to

Comments / Concerns

Do you have any questions, comments or concerns regarding this claim?

Employment Information

Employee’s Job Title*

Social Security Number*

Date of Birth*

Date of Hire*

End Date

This worker was hired to work on a temporary basis

Name of Temporary Project

Project Start Date

Project End Date

This worker was dispatched by a union

Union Name

Employment Information

Date of Injury or last occupational exposure (OD)*

Location where the injury/OD occurred*

When was the injury reported?*

Who was the injury reported to?*

What time was the injury reported?*

Description of how the incident occurred*

Body part(s) injured or exposed, including side of body*

Wage Information

If your employee has hours or wages that vary, including if they work overtime or are paid by piece or job, please send payroll records to [email protected]. We request 12 months payroll prior the date of injury. Or as much as you have, if they have worked less than 12 months.

Rate of Pay*

Hours Per Day*

Days Per Week*

Multiple rates of pay?

Units of work?

Tips?

Amount $

Per

Fuel?

Amount $

Per

Housing/board?

Amount $

Per

Commision?

Amount $

Per

Bonus in the 12 months prior to the date of injury?

Amount $

Per

Bonus Period Start Date

Bonus Period End Date

Overtime in the 12 months prior to the date of injury?

No. of overtime hours

Will the injured worker will be kept on salary for this industrial injury?*

Note: kept on salary (wage replacement benefits) excludes: vacation pay, sick leave, holiday pay, paid time off, or similar types of compensation

Health Care Benefit Information

Health care benefits were being paid for the worker and/or the worker’s family at the time of injury

If checked, what amount did you pay for health care benefits only? (do not include pensions, disability insurance or other considerations) $

Per

Employer-paid health care coverage has ended

If checked, what was the last date covered?

If payments for health care benefits are ongoing but there is an anticipated coverage end date, please provide the date

Health benefits are managed by a trust or union

Trust/Union Name

Phone Number

Return To Work Information

The injured worker missed time from work

If checked, what specific dates were missed?

Light duty work will be available if the worker is released to modified duty

Light duty comments?

The injured worker has returned to work

Date last worked

Date returned to work

If the injured worker has returned to a light duty position, how many hours per day?

How many days per week?

Position

Finishing Up

Completed by*

Date*

Phone Number*

Email Address*