This form should be completed whenever an employee incurs and injury that happens in the workplace. This form needs to completed with as many details as possible as soon as possible. Also, be sure to complete an incident report for your specific work location where the incident occurred. Failure to report and submit your completed claim form within fifteen (15) calendar days of the incident will not be submitted through worker's comp and the employee will need to seek his/her medical care through their personal health insurance provider(s).