Workers' Comp Complaint Generator | Free State Court Tool

Court & Jurisdiction

Where will you file your workers' compensation complaint?

Workers' compensation claims are filed in the state where you worked and were injured.

State *

County or District

Jurisdiction Statute

Optional: specific statute citation for jurisdiction

Venue Statute

Optional: specific statute citation for venue

Venue Reason

Workers' Comp Act Citation

Optional: your state's workers' compensation statute

About You

Tell us about yourself (the claimant).

Full Legal Name *

Address

County of Residence

Your Employer

Information about your employer and their insurance carrier.

Employer Legal Name *

Employer Entity Type

Employer County

Employer Address

Insurance Carrier Name

Insurance Carrier Address

Policy Number

Employment Details

Information about your job and wages.

Job Title *

Average Weekly Wage

Your average earnings per week before the injury

The Incident

When and how did the injury occur?

Date of Injury *

Time of Injury

Location of Injury

Specific Task Being Performed

Specific Location on Premises

Hours Worked Prior to Incident

Detailed Description of Work Being Done

Description of Incident *

Injury Details

What injuries did you sustain?

Primary Injury Type

Secondary Injury Type

Additional Injuries

Psychological Injuries (check all that apply)

Anxiety

Depression

PTSD

Sleep disturbance

Fear/phobias

Cognitive impairment

Other

Immediate Symptoms

Conditions & Safety

Environmental conditions and safety equipment at time of injury.

Lighting Conditions

Weather Conditions

Equipment Condition

Known Hazards or Prior Complaints

Medical Treatment

Medical care received and benefits status.

Treating Providers

Medical Treatment Received (check all that apply)

Emergency room visit

Hospital admission

Surgery

Physical therapy

Chiropractic care

Prescription medications

X-rays/imaging

Injections/pain management

Other

Additional Treatment Details

Ongoing Treatment Needs

Compensation Rate (per week)

Permanent Disability (%)

Benefits Status

Terminated As Of (if applicable)

Notice to Employer

How and when did you notify your employer about the injury?

Most states require you to notify your employer of a work injury within a specific timeframe.

Date Notice Given

Person Notified

Notice Method

Verification & Service

Verification State

Verification County

Service Date

Service Method

Employer Service Address

Review Your Complaint

Review your information below. Click "Generate Complaint" when ready.

⚠️ Important Disclaimer
This is an AI-generated document and should serve only as a starting point. Review carefully for accuracy before filing.

Workers' Compensation Complaint Generator