Independent Contractor WCF Claim

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If an independent contractor sustains a shift-related injury or illness, it is important to notify the facility and Nursa immediately. Once this form is completed, Nursa will file the claim with the insurance company (Worker Compensation Fund). After the claim is started, a WCF adjuster wiIl be assigned to your claim.

In cases of true medical emergencies, report to the nearest emergency room.

Today's Date *

YYYY

Name of Person Injured *

Last 4 SSN of Injured Individual *

DOB of Injured Individual *

YYYY

Mailing Address of Injured Person *

Date of Injury *

YYYY

Time of Injury *

Time

Which state did the injury occur in? *

Address of location of injury *

Part of Body Injured (include which side) *

Describe how the injury occurred *

What medical attention was sought? *

No medical attention

Minor care

Professional provider care

Urgent care/emergency room

Other:

If medical attention was sought, what is the address of the provider? *

If the injury occurred at a facility, what is the facility phone number and email address? *

Name of Person Filling Out Form *

Submit

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