Refusal to File Workers Compensation Benefits
by Kirk Williamson, from the Community
This template documents an employee decision to refuse filing workers compensation benefits and decline medical treatment following a reported workplace injury. It provides structured fields for employee and supervisor names, job name or number, location, document number, and the date and time of signature. The statement section records acknowledgement that a claim form and medical care were offered and declined, and that the signature is voluntary. Use this form to capture essential details, maintain compliance records, and ensure clear acknowledgment with printed names and signatures.
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About author
This community page makes available free workplace checklists and templates created by other users within the SafetyCulture community. SafetyCulture has re-published this content and where possible, has credited the original author. SafetyCulture has not verified the accuracy, reliability or suitability of any community content. You agree that your use of any of this content is in accordance with SafetyCulture’s Terms and Conditions.