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Client Details
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Business Unit:
Notification Type
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Employment Type
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Case Information
{{model.uiRules.LastDayWorkedRule.Alias || 'Last Day Worked'}}
{{model.uiRules.FirstDayAbsentRule.Alias || 'First Day Absent'}}
{{model.uiRules.StdStartDateRule.Alias || 'STD Start Date'}}
{{model.uiRules.LtdEffectiveDateRule.Alias || 'LTD Effective Date'}}
{{model.uiRules.AnyOCCEffectiveDateRule.Alias || 'Any OCC Effective Date'}}
{{model.uiRules.AccommodationStartDateRule.Alias || 'Accommodation Start Date'}}
{{model.uiRules.DateOfInjuryOrIllnessRule.Alias || 'Date of Injury or Illness'}}
{{model.uiRules.LeaveEffectiveDateRule.Alias || 'Leave Effective Date'}}
{{model.uiRules.NumberOfAbsencesRule.Alias || 'Number of Absences'}}
{{model.uiRules.DatesOfAbsencesRule.Alias || 'Dates Absent'}}
Absent Date
Is Result Of Underlying Medical Condition
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No
Submit Case Information
Incident Information
Employee Was Sent Package
Yes
No
Was EFAP offered (if applicable)
Yes
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Client Claim Id
Did EE Have An Accident
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Sick Credit Days
EE Expected return to work date
Accident Location
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Work
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Client Details
Salutation
{{getDescription(salutation, 'en')}}
First Name
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Middle Name
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Last Name
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Employee Number
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Palau
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Puerto Rico
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Washington
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Work City
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Home Email
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Primary Telephone Number
Alternate Phone
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Work Phone (Ext)
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Work Email
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Mobile Phone same as Primary Number
Mobile Phone
Employment Information
Job Title
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Date Hired
Wage
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Wage Unit
{{getWageUnitDescription(wType.WageUnitType, wType.Alias || wType.WageUnitType)}}
Union Affiliation
{{getDescription(un, 'en')}}
Employee Work Schedule Type
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Employment Work Schedule
Is Transitional Work Available
Yes
No
Transitional Duties
Yes
No
Transitional Hours
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No
Please Describe
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Does Employee Work Shifts
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No
Shift Type
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Work Performance Issues
Attendance Issues
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Addressed?
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No
Description
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Interpersonal Relations
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No
Addressed?
Yes
No
Description
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Productivity
Yes
No
Addressed?
Yes
No
Description
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Other
Yes
No
Addressed?
Yes
No
Description
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Area Of Complaint
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Expected RTW date
Expected RTW Time
Yes
No
{{item.TextLocale | highlight: $select.search}}
{{item.TextLocale | highlight: $select.search}}
WCB Incident Information
WCB Provincial Board
{{value}}
Accident Category
Accident Category
{{value}}
{{model.uiRules.IncidentDateRule.Alias || 'Incident Date'}}
{{model.uiRules.IncidentTimeRule.Alias || 'Incident Time'}}
{{model.uiRules.ERNotifiedDateRule.Alias || 'ER Notified Date'}}
Cause of Injury
{{injuryCause.Description}}
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Primary
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Nature of Injury
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Primary
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Body Part
Body Part
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Body Part Subarea
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{{bodyPartItem.BodyPartSubAreaDescription || bodyPartItem.BodyPartSubArea}}
Accident Location
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Completed By
Name
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Phone
Confirmation Email
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Completed By Job Title
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Additional Comments
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Invoicing Details
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Cost Centre
Ergo Assessment Type
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Preferred Product Vendor
Billing Address Line 1
Billing Address Line 2
Country
Australia
Canada
Puerto Rico
United States of America
Prov / State
Alabama
Alaska
Alberta
American Samoa
Arizona
Arkansas
Armed Forces - Americas
Armed Forces - Europe/Africa/Canada
Armed Forces - Pacific
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
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Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland and Labrador
North Carolina
North Dakota
Northern Mariana Islands
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
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Palau
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Prince Edward Island
Puerto Rico
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Rhode Island
Saskatchewan
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South Dakota
Tennessee
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