The Workers Compensation Claim Toolkit

Labor and Employment > Workers Compensation | Published 25 February 2026 - Updated 24 August 2026 | UpLaw - uplaw.us

Module 1 takes ten minutes and is done in the first hour. Nothing later in this toolkit repairs a missing Module 1.

Keywords: incident record, notice, deadlines, medical control, wages, causation, IME, light duty, third party, liens, settlement

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Module 1 — First-hour incident record

Fill this out on a phone, at the scene, before anyone cleans up.

Date: ______ Clock time: ______ Shift start: ______ Location, specifically: ______________________________ What I was doing — object, weight, height, motion, direction:

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What I felt, and where (list every body part, including minor ones):

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Witnesses — name, role, phone: ______________________ Supervisor told: ______ At: ______ Said: ______________ Photographs taken: ☐ Scene ☐ Equipment ☐ Missing guard/warning ☐ Injury ☐ Manufacturer plate, model, serial Equipment owner — employer or someone else? ______________ Anyone from another company present? ______________ Incident report: ☐ Completed ☐ Copy requested ☐ Refused ☐ None exists Did I sign anything? ☐ No ☐ Yes — what: ______________

⚠ Do not finish the shift. The most common act that undermines a claim is working three more days to be a good sport.

Why the equipment plate matters. If the machine, vehicle, or tool was made or owned by anyone other than the employer, there may be a third-party claim — which carries pain and suffering, full wage loss, and a jury, none of which the compensation system provides. Module 10 screens for it. The serial number photographed in the first hour is often the only reason that claim survives.

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Module 2 — Written notice template

Send within days, in writing, from a personal email address.

To: Supervisor and HR Subject: Written notice of work injury — [name], [date of injury]

"This is written notice of a work injury.

On [date] at approximately [time], while [exact task — object, weight, height, motion], I injured my [list every body part].

I reported this to [name] on [date] at approximately [time].

I was seen at [provider] on [date]. My current work restrictions are [restrictions], dated [date].

Please confirm receipt and provide: (1) the carrier's name, adjuster, and claim number; (2) the authorized treating providers and the procedure for changing providers; (3) a copy of the employer's first report of injury; (4) my payroll records for the applicable average weekly wage period; and (5) confirmation of whether any leave has been designated for this absence and the date it began.

Please send to [personal email]."

☐ Sent from personal address ☐ Copy saved off company systems ☐ Notice deadline confirmed ☐ Read receipt or reply obtained

Why the personal address. Company email access ends on the day of separation, and with it the proof that notice was ever given.

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Module 3 — Deadline calculator

Date of injury / disablement: ______ Date employer notified — orally: ______ in writing: ______

NOTICE TO EMPLOYER State window: ______ days · Due: ______ ☐ Met ☐ Late — if late, is prejudice required? ______

CLAIM FILING WITH THE AGENCY State window: ______ · Trigger used: ☐ injury ☐ last payment ☐ employer report ☐ discovery Due: ______ ☐ Calendared in three places ⚠ Voluntary payment of benefits may restart this clock. Confirm before relying on it.

DENIAL APPEAL — window: ______ days · Due: ______ UTILIZATION REVIEW APPEAL — window: ______ · Due: ______ CHANGE OF PHYSICIAN WINDOW — opens ______ closes ______

THIRD-PARTY TORT CLAIM — separate and usually shorter. Due: ______

PARALLEL CLAIMS ☐ Safety-complaint retaliation — 30 days, 29 U.S.C. § 660 — Due: ______ ☐ Discrimination charge — 180 / 300 days, 42 U.S.C. § 2000e-5 — Due: ______ ☐ Leave claim — 2 years, 3 if willful, 29 U.S.C. § 2617 — Due: ______ ☐ Benefit plan claim — 29 U.S.C. § 1132 — plan deadline: ______

OCCUPATIONAL DISEASE / CUMULATIVE TRAUMA Trigger used by this state: ☐ disablement ☐ diagnosis ☐ discovery ☐ last injurious exposure ☐ last day worked Recomputed due date: ______ — a claim that is late under one trigger is frequently timely under another.

General timeliness doctrine: Statutes of Limitations and Repose: A Comprehensive Guide to Accrual, Tolling, and Revival and Calculating and Preserving a Limitations Deadline: A Practical Checklist.

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Module 4 — Medical control worksheet

Which model does this state use? ☐ Employer/carrier directs — panel posted? ______ providers listed: ______ ☐ Worker chooses freely — network restrictions? ______ ☐ Employer directs, then one change — change available after: ______ Window closes: ______ ☐ Managed care organization — internal change process: ______

Current treating physician: ______________ Since: ______ Is the chart helping or hurting? Read the last three notes and mark: ☐ Causation stated affirmatively ☐ Restrictions specific and current ☐ Objective findings documented ☐ ⚠ "Subjective complaints out of proportion" ☐ ⚠ "Symptom magnification" ☐ ⚠ No mechanism recorded

Change decision: ☐ Stay ☐ Change — if changing, do it before the record hardens, not after.

Mileage log started? ☐ Yes — reimbursable in most states, claimed in almost none.

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Module 5 — Average weekly wage audit

Twenty minutes. Frequently the highest-value twenty minutes in the case.

Lookback period used by the carrier: ______ weeks · Carrier's AWW: $______ Payroll records requested: ☐ Yes, on [date] ☐ Received

Component	In carrier's figure?	Should it be?	Amount
Base wages	☐	Yes
Overtime	☐	Often — check regularity
Shift differentials	☐	Usually
Tips / gratuities	☐	If reported
Commissions	☐	Usually, averaged
Production bonuses	☐	Sometimes
Second job (concurrent employment)	☐	In many states, yes
Employer housing / meals / vehicle	☐	Sometimes

Special rules to check: ☐ Employed less than the lookback → similar employee wages ☐ Seasonal worker → seasonal formula ☐ Minor with predictable wage growth → adjusted wage ☐ Irregular schedule → divisor by weeks actually worked

Corrected AWW: $______ Difference: $______ Weekly benefit impact: $______ Over ______ weeks = $______ Plus proportional increase in every permanent benefit derived from AWW.

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Module 6 — The causation letter

The single sentence most compensation charts are missing. Give this to the treating physician.

To: [Physician] Re: [Patient], DOI [date], claim no. [____]

"To support this patient's claim, the record needs an explicit causation statement. Would you please address the following in a chart note or letter:

1. The mechanism of injury as the patient described it on [date].

2. Your diagnosis, and the objective findings supporting it — imaging, examination findings, and clinical testing.

3. Whether, to a reasonable degree of medical certainty, the work event of [date] caused the condition, or aggravated, accelerated, or combined with a pre-existing condition to produce the current disability.

4. If pre-existing degenerative change is present, whether it was symptomatic before [date], and what changed after.

5. Current work restrictions, with specific weights, postures, and durations.

6. Whether the patient has reached maximum medical improvement, and if so, the impairment rating and the guide edition used.

7. Anticipated future treatment, including the probability and estimated cost of surgery."

Item 4 wins pre-existing-condition denials. Everyone over thirty-five has degenerative change on imaging. The question is never what the film shows. It is what changed, and when.

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Module 7 — Utilization review appeal template

Denied request: ______________ Denial date: ______ Appeal due: ______ Guideline cited by the reviewer: ______________

Resubmission must contain, in this order: ☐ Objective findings — imaging, examination, testing, with dates ☐ Failed conservative care — modality, duration, dates, outcome ☐ Functional deficits — what the patient cannot do, measured ☐ The guideline's own criteria, quoted, with the facts matched to each ☐ Statement of medical necessity to a reasonable degree of medical certainty ☐ Consequence of denial — expected deterioration, and its cost

⚠ "Patient needs MRI" gets denied. "Six weeks of failed physical therapy, positive straight-leg raise at 40 degrees, progressive foot drop" gets approved. The difference is not the medicine; it is the sentence.

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Module 8 — Independent medical examination: prepare and debrief

8A — Before

☐ Written list prepared: every body part, every symptom, every medication, every provider, every prior injury to the same area ☐ Prior injuries disclosed — they will be found; disclosed they are history, concealed they are impeachment ☐ Typical-day description rehearsed — not the best day, not the worst ☐ Observer or recording arranged, if the state permits ☐ Arrive early; note the appointment time and the actual start and end of the physical examination

8B — During

☐ Answer only what is asked ☐ Do not minimize; do not exaggerate ☐ Give way on strength testing only where it genuinely gives way — effort testing is built in ☐ Note what was and was not examined

8C — Same-day debrief

Appointment scheduled for: ______ Physical exam started: ______ Ended: ______ Total minutes with the physician: ______ Tests actually performed: ______________________________ Tests NOT performed: ______________________________ Records the examiner had: ______________________________ Statements the examiner made: ______________________________

⚠ A report describing a comprehensive twenty-minute neurological examination is hard to defend when the appointment lasted nine minutes. The debrief sheet is the only contemporaneous record of that, and it must be written the same day.

☐ Report requested and compared line by line against the debrief.

And assume surveillance exists in any case with meaningful permanent exposure. Everyone carries groceries. The problem is only ever the person who told the examiner they could not.

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Module 9 — Light-duty response letter

Offer received: ☐ In writing ☐ Verbally only — if verbal, request it in writing before responding Job title: ______ Hours: ______ Location: ______ Start: ______

Line-by-line comparison

Task in the offer	Physical demand	Current restriction	Conflict?
			☐
			☐
			☐

If there is no conflict: TAKE THE JOB. Refusal generally ends wage benefits.

If there is a conflict, respond in writing — do not simply refuse:

"Thank you for the offer of modified duty dated [date]. My current restrictions, dated [date] from [physician], are [restrictions]. The position as described requires [specific task], which exceeds [specific restriction]. I am able and willing to perform work within my restrictions. Please revise the offer, or ask [physician] to address whether these specific tasks are within my restrictions. I will start immediately on a corrected offer."

If the offer appears to be a sham — a job invented to force a refusal, at an unreasonable distance, or on an impossible schedule — document contemporaneously: ☐ Did the position exist before? ☐ Is anyone else doing it? ☐ Distance and commute ☐ Shift change ☐ Pay reduction

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Module 10 — Third-party screening form

Run this at intake. Not at settlement.

1. Was a machine, tool, vehicle, chemical, ladder, or scaffold involved? ☐ Yes ☐ No Manufacturer: ______ Model: ______ Serial: ______ Owner: ______ ☐ Guard, warning, interlock, or safety device missing or defective?

2. Who owned or controlled the premises? ______________ ☐ Employer ☐ Someone else → premises claim. See Premises Liability: A Comprehensive Guide to Duty, Notice, Dog Bites, and Negligent Security

3. Was another contractor's crew working nearby? ______________

4. Was a motor vehicle involved? ☐ Yes → Motor Vehicle Injury Claims: A Comprehensive Guide to Liability, Coverage, Damages, and Settlement

5. Was the worker a temp or staffing-agency employee? — the host employer may or may not share immunity, depending on the state.

6. Did OSHA inspect? ☐ Yes → request the file. Photographs, measurements, and witness statements created by someone with no stake in the compensation claim.

7. Evidence preservation letter sent? ☐ Yes, on ______

"We request that the [equipment] involved in the [date] incident be preserved in its current condition and not repaired, altered, tested, or discarded pending inspection."

8. Tort limitation period computed separately? ☐ Yes — Due: ______

Exclusive remedy bars claims against the employer. It bars nothing else. This module is where the largest recoveries in workplace-injury practice are found, and it is the module most often skipped.

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Module 11 — Lien and offset worksheet

Lien holder	Amount asserted	Reduced by fees/costs?	Negotiated to	Resolved
Compensation carrier		☐ common fund		☐
Health plan (29 U.S.C. § 1132)		☐		☐
Medicaid		☐		☐
Medicare		☐		☐
Providers / letters of protection		☐		☐
Child support arrears		☐		☐

Questions to resolve on the compensation lien: ☐ Does this state apply the common fund doctrine to reduce the lien by a pro rata share of fees and costs? ☐ Does the lien reach non-economic damages or only paid categories? ☐ Does the carrier get a future credit against benefits? ☐ Does the employer's own comparative fault reduce the lien?

Offsets: ☐ SSDI — combined benefits capped at a statutory percentage of prior earnings. Proration language in the settlement controls. Allocation over remaining life expectancy at a stated monthly rate: ☐ drafted ☐ Medicare — future injury-related medical addressed: ☐ set-aside considered ☐ documented ☐ Unemployment — concurrent receipt offset or barred? See Unemployment Insurance: A Comprehensive Guide for Claimants and Employers ☐ Employer-funded disability plan or pension — offset by plan terms?

Gross settlement: $______ − liens $______ − fees $______ − costs $______ = NET $______

⚠ Never quote a client a gross number. The disappointment at the closing table is entirely avoidable and entirely the lawyer's fault.

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Module 12 — Settlement review grid

Item	Present?	What it does	Check before signing
Shape of settlement	☐	Stipulated award vs. full and final	Which one, in the client's own words
Indemnity amount	☐	The cash	Derived from the corrected AWW
Future medical	☐	Open or closed	Priced by someone who has seen the surgery priced
Medicare interest	☐	Future injury-related care	Addressed, not ignored
SSDI proration	☐	Offset control	Language present
Liens	☐	Reduce the net	Quantified and resolved, not "mentioned"
Tax treatment	☐	Generally excludable	Confirm; wage-replacement vs. other components
Resignation / no-rehire	☐	An employment agreement in disguise	Value it separately — see Termination, Severance, and Final Pay: A Comprehensive Guide for Employees and Employers
General release language	☐	May sweep in other claims	Does it release the third-party claim? The discrimination claim?
Approval	☐	Agency or judicial	Required in most states
Reopening rights	☐	Change of condition	Preserved or waived
Vocational rehabilitation	☐	Retraining, placement	Frequently undervalued

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Module 13 — Employer response protocol

Within 24 hours ☐ Medical care arranged ☐ Scene photographed ☐ Equipment preserved ☐ Witness statements taken ☐ Incident report completed and a copy given to the employee

Within the statutory window (often days) ☐ Report to carrier ☐ Report to state if required ☐ Recorded on the injury log — 29 CFR Part 1904 ☐ Accurate wage statement provided — an inflated or deflated AWW creates penalty exposure either way

Ongoing ☐ Light-duty offers in writing, matched line by line to the written restrictions ☐ Leave designated and the employee told the start date — 29 U.S.C. § 2612, 29 CFR Part 825 ☐ Litigation hold issued if a claim is foreseeable ☐ Certificates of insurance collected from every subcontractor — otherwise you are their statutory employer and do not know it

At maximum medical improvement ☐ Permanent restrictions obtained in writing ☐ Accommodation process engaged on the record — 42 U.S.C. § 12112, 42 U.S.C. § 12111, 29 CFR Part 1630 ☐ Limits understood: seniority systems, US Airways, Inc. v. Barnett, 535 U.S. 391 (2002); direct threat, Chevron U.S.A. Inc. v. Echazabal, 536 U.S. 73 (2002); neutral no-rehire policies, Raytheon Co. v. Hernandez, 540 U.S. 44 (2003)

Never ☐ Terminate a claimant without a documented, independent, pre-existing reason — retaliation sits outside exclusive remedy, and the adverse-action standard is broad: Burlington Northern & Santa Fe Railway Co. v. White, 548 U.S. 53 (2006) ☐ Treat an OSHA citation and a compensation claim as the same proceeding — 29 U.S.C. § 654, 29 U.S.C. § 660 ☐ Ignore a pattern. Three similar injuries on one task is a safety problem before it is a claims problem.

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Module 14 — Hearing preparation outline

I. Compensability ☐ Notice — date, form, recipient, proof ☐ In the course of — time, place, activity ☐ Arising out of — the risk framework this state uses ☐ Defenses raised and the evidence answering each

II. Medical causation ☐ Treating physician's opinion, in writing, with the magic words ☐ Prior treatment to the same body part, disclosed and explained ☐ Aggravation vs. natural progression ☐ IME weaknesses from the Module 8 debrief

III. Wages and benefits ☐ Corrected AWW with payroll exhibits ☐ Periods of TTD and TPD, with the restrictions supporting each ☐ Light-duty offers and the written responses

IV. Permanency ☐ MMI date ☐ Rating and guide edition ☐ Schedule vs. whole person vs. wage loss ☐ Vocational evidence if the state uses earning capacity

V. Penalties ☐ Every late payment, with dates

VI. The worker's testimony ☐ Short, specific, consistent with every form ever signed ☐ Rehearsed on the inconsistency the carrier will raise — the true explanation is usually enough, and judges have heard it a thousand times

Evidentiary framing borrows the federal analogues at Federal Rules of Evidence § 803 for records and Federal Rules of Evidence § 702 for expert reliability.

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Reference table — the federal authorities

Provision	Subject
5 U.S.C. § 8101	FECA definitions
5 U.S.C. § 8102	FECA entitlement
5 U.S.C. § 8106	Continuation of pay
5 U.S.C. § 8128	No judicial review
33 U.S.C. § 901	Longshore Act
33 U.S.C. § 904	Employer liability
33 U.S.C. § 905	Exclusivity; vessel negligence
33 U.S.C. § 908	Compensation schedule
33 U.S.C. § 919	Claim procedure
33 U.S.C. § 921	Review
46 U.S.C. § 30104	Jones Act
45 U.S.C. § 51	FELA
45 U.S.C. § 56	FELA limitation
30 U.S.C. § 901	Black lung
29 U.S.C. § 654	OSHA general duty
29 U.S.C. § 660	Safety retaliation, 30 days
29 U.S.C. § 2615	Leave interference
42 U.S.C. § 12203	Disability retaliation
29 U.S.C. § 216	Wage claim enforcement
42 U.S.C. § 2000e-3	Title VII retaliation

Leading cases: Valladolid · Rambo · Howlett · Cleveland v. Policy Management · Barnett · Echazabal · Hernandez · Burlington Northern · Muldrow v. City of St. Louis, 601 U.S. 346 (2024).

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Reference table — the calendar

When	What
Hour 1	Module 1. Stop working. Photograph everything
Day 1	Module 2 phrasing at the first medical visit
Days 1–7	Module 2 written notice. Module 3 deadlines
Weeks 1–2	Module 4 medical control. Module 5 wage audit
Week 2+	Module 6 causation letter. Module 10 third-party screen
On denial	Appeal deadline. Claim petition
On UR denial	Module 7, expedited
On IME notice	Module 8
On light duty	Module 9, in writing, same week
At MMI	Rating. Accommodation conversation. Module 11
At settlement	Modules 11 and 12, before signature

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Reference table — what the words mean

The carrier says	It means
"Maximum medical improvement"	Stabilized — not recovered, and not pain-free
"Independent medical examination"	Carrier-selected, carrier-paid, one appointment
"Utilization review"	A file review by someone who has not met you
"Modified duty available"	Wage benefits stop if you refuse — check the restrictions first
"Impairment rating"	A number from a guide, converted by statute into weeks
"Full and final compromise"	Future medical is yours forever
"Subrogation"	The carrier is repaid from your third-party recovery
"Apportionment"	Part of the disability is being assigned to something other than work
"Pre-existing condition"	Not a defense if work aggravated it
"Voluntary payment without prejudice"	Benefits now; no admission, and possibly a restarted clock

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Related Documents

Articles

• Hurt at Work: How a Workers Compensation Claim Actually Moves
• It Was Wet and Nobody Said So: How Premises Liability Cases Are Won and Lost
• The Hours You Worked and Were Not Paid For: How Wage Theft Actually Happens
• Five Steps and a Grid: How the Government Decides Whether You Are Disabled
• The General Duty Clause: How OSHA Regulates Hazards It Never Wrote a Standard For
• The First Two Weeks After a Crash: What You Do Now Decides What the Case Is Worth

Guides

• Workers Compensation Claims: A Comprehensive Guide to Notice, Benefits, Disputes, and Settlement
• Workers' Compensation: A Comprehensive Guide to Coverage, Benefits, and Claim Disputes
• Workplace Safety Under the OSH Act: A Comprehensive Guide
• Leave and Accommodation: A Comprehensive Guide to the FMLA, the ADA, and Pregnancy Protections
• Social Security Disability: A Comprehensive Guide to SSDI, SSI, and the Appeals Process
• ERISA: A Comprehensive Guide to Plan Governance, Fiduciary Duty, and Benefit Claims

Checklists

• Filing and Pursuing a Workers Compensation Claim: A Practical Checklist
• Responding to an OSHA Inspection and Citation: A Practical Checklist
• Requesting Leave or a Workplace Accommodation: A Practical Checklist
• Filing and Appealing a Social Security Disability Claim: A Practical Checklist
• Documenting and Presenting a Premises Liability Claim: A Practical Checklist

Toolkits

• The Workplace Injury and Safety Toolkit
• The Employee Leave and Workplace Accommodation Toolkit
• The Termination and Severance Toolkit
• The Social Security Disability Toolkit
• The Auto Injury and Insurance Claim Toolkit