Claim kit - OCMI Workers Comp

Clients forms

WORKERS COMP

CLAIM KIT

FORM

What is a Workers Comp Claim Kit?

A necessary form is required by Florida Comp laws in the event of a work-related injury or illness to receive benefits such as medical treatment or other workers comp benefits.

This is how to file a workers comp claim as soon as an event has occurred.Fill out this form when you are ready.

Clients forms

Workers Comp Certificate Request

Employee Onboarding

Employee Time Reporting

Recurring Payment Authorization

Client Authorization to Debit/Credit

Direct Deposit

Client Affidavit Of Zero Wages

Separation Notice

Workers Comp Claim Kit

Filing a Workers Comp Claim

If you just had a jobsite accident to report, make sure you have done the following injury checklist:

● Inform the facility that there was a jobsite injury (workers comp).

● Inform the facility that a mandatory drug screening is required with treatment.

● Give the medical facility the Cornerstone’s claims department
(609) 451-0113 EXT 114 & claims@cornerstonepeo.com email for billing and treatment instructions.

● (609) 451-0113 and speak to a Cornerstone representative

● Complete the injury report below right away!

Note: All initial treatment, follow up treatment, and benefits MUST BE PROCESSED THROUGH THE INSURANCE COMPANY. Follow up treatments or therapy’s will not be covered outside of the carrier’s network.

We are dedicated to providing the best treatment and benefits to the injured employee. We will be in contact with you quickly.

Thank you!

Cornerstone Claims Team

Your Company Information

Company Name

Employee Identifying Information

Employee Name

Employee ID #

Type of identification

Physical Address

City

State

Zip

Phone Number

Work Phone Number

Cell Phone Number

Work Email

Personal Email

Mailing Address (If same as Physical Address, leave it blank)

Accident Detail

Time of Accident

Date of Accident

Date Reported

Type of Report

Accident Description (50 characters)

Claim Summary (Include any relevant details)

Initial Medical Treatment

Hospital, Urgent care, Doctor information

Name

Address

City

State

Zip

Phone Number

Fax

Add file (1 MB)

*Any official bank form displaying the company name, routing and account number are also accepted (PDF, JPEG, JPG, PNG)

Witness Information & Statement

Name

Title

Work Phone Number

Personal Phone Number

Notes / Statement

I, the undersigned witnessed or am reporting the injury by personal observation or reported by the listed witness, and I do hereby affirm that each and every declaration I’ve made in the above-referenced report of injury or illness is true and correct to the best of my ability. I further affirm I have made the declarations of my own free will, without coercion, promises or enticements of any type. I voluntarily present this information, and with this authorization, hold harmless any recipient of the information who uses or shares the information in any way. I know that any falsification of information herein may result in a criminal matter and that any person who knowingly presents a false statement for the fraudulent payment of a loss is guilty of a crime, and may be subject to fines and confinement in a state prison.

Authorized Representative

Name

Phone Number

● Inform the facility that there was a jobsite injury (workers comp).

● Inform the facility that a mandatory drug screening is required with treatment.

● Give the medical facility the Cornerstone’s claims department(609) 451-0113 EXT 114 & claims@cornerstonepeo.com email for billing and treatment instructions.

● (609) 451-0113 and speak to a Cornerstone representative

● Complete the injury report below right away!

Your Company Information

Employee Identifying Information

Accident Detail

Hospital, Urgent care, Doctor information

Witness Information & Statement

Authorized Representative

● Give the medical facility the Cornerstone’s claims department
(609) 451-0113 EXT 114 & claims@cornerstonepeo.com email for billing and treatment instructions.