Nationwide Workers’ Compensation Surplus Funds Claim

What Is a Workers’ Compensation Claim

Workers’ compensation provides financial benefits to employees who were injured, became ill, or were otherwise entitled to benefits through employment. Surplus workers’ compensation funds may exist when funds were not fully claimed, misallocated, or left uncollected due to administrative delays or outdated records.

Why the Claim Form Must Be Completed

Completing the official claim form is required to:

Verify the claimant’s identity
Confirm employment and benefit eligibility
Locate and release any available workers’ compensation surplus funds

Only eligible individuals who complete the form can be reviewed for payment.

Instruction Notice

To begin your Workers’ Compensation Surplus Funds claim, please complete the form below with accurate and complete information.

Official Workers’ Compensation Surplus Funds Claim Form

Submission of this form is required to verify identity, confirm eligibility, and facilitate the lawful release of any Workers’ Compensation surplus funds to qualified claimants.

Section A: Personal Identification Information

Full Legal Name (As Shown on Government ID)

Date of Birth (MM/DD/YYYY)

Place of Birth (City and State)

Marital Status

Section B: Parental Information (For Identity Verification)

Father’s Full Legal Name (First and Last)

Mother’s First Name

Mother’s Last Name

Mother’s Maiden Name

Section C: Address History

Current Residential Address

Previous Residential Address

Current Mailing Address

Previous Mailing Address

Section D: Government-Issued Identification

Accepted IDs include Driver’s License, State ID, or other government-issued photo identification.

Government-Issued Identification Card (Front Image)

Government-Issued Identification Card (Back Image)

Section E: Employment & Income Documentation

Please upload images or scanned copies of any applicable documents.

W-2 (Wages from an Employer)

1099 Forms (NEC, MISC, INT, DIV, K, etc.)

Unemployment Compensation (1099-G)

Social Security Benefits (SSA-1099)

Retirement or Pension Income (1099-R)

Section F: Banking Information (For Direct Deposit)

Name of Financial Institution

Bank Account Number

Routing Number

Section G: Identity Verification History

Please indicate any identity verification service you have previously used:

Section H: Employment History

Current Occupation

Previous Occupation

Section I: Tax Identification

Social Security Number (SSN) or ITIN

Account Security

Email Address (Will be used for login)

Mobile Phone Number

Create Password

By submitting this form, I certify that all information provided is true, accurate, and complete. I authorize verification of submitted information for Workers’ Compensation surplus fund eligibility. I understand that submission does not guarantee payment and approved funds will be disbursed via direct deposit upon successful verification.