Sample Report of Workers' Compensation for employment screening and background check

Please note: Every search result varies depending on the individual.

Workers' Compensation

Name:	TERESA SMITH	Date of Birth:	NOT LISTED
Address:	140 E. SQUARE AVE., DENVER, CO 80202	SSN:	001-01-XXXX
Sex:	FEMALE	Age:	35
State:	COLORADO	Number:	9018563
Injury Date:	10/24/1990	Returned to Work:	03/18/1991
CMP Paid:	$156	MED Paid:	$1,804
Disablement:	Temporary Total	Injury Type:	MISCELLANEOUS OR MULTIPLE
Injury Location:	Upper Arm	Injury Source:	USING TOOL OR MACHINE
Employer Name:	ACE MACHINE , INC.	Date Hired:	10/31/1983
= = = = = = = = END OF REPORT = = = = = = = = (This is a sample report. This may not reflect your actual report.)

Workers' Compensation

Some states require a Release Form signed by the subject.
(You can find the necessary form Here)