Workers Compensation Insurance

Patient Information

Duramedic Account Number Hospital

Patient Name

Mailing Address

City State Zip Code

Phone Number

Email Address

Workers Compensation Information

Employer

Employer's Physical Address

City State Zip Code

Worker's Compensation Carrier

Claims Mailing Address

City State Zip Code

Carrier's Phone Number Carrier's Fax Number

Adjuster's Name

Claim Number * If claim # is not known, enter patient's Social Security Number

Date of Injury