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Workers compensation - first report of injury or illness

Employer (Name & Address):
Industry Code:
Employer Fein:
Carrier/Administrator Claim Number:
Report Purpose Code:
Jurisdiction Claim Number:
Insured Report Number:
OSHA Case Number:
Employer's Location Address (If Different):
Location #:
Phone #:
Carrier/Claims Administrator
  Self Insurance
Carrier (Name, Address & Phone No):
Carrier Fein:
Policy/Self-Insured Number:
Administrator Fein:
Policy Period: To
Claims Administrator (Name, Address & Phone No):
Agent Name & Code Number:
Name (Last, First, Middle):
Address (Include Zip):
Date of Birth:
Marital Status:
# Dependents:
Social Security Number:
Date Hired:
State Hire:
Occupation/Job Title:
Employment Status:
NCCI Class Code:
Average Weekly Wages:
# Days Worked/Week:
Full Pay for Day of Injury?
Did Salary Continue?
Time Employee Began Work:
Date of Injury/Illness:
Time of Occurrence:
Last Work Date:
Date Employer Notified:
Date Disability Began:
Contact Name/Phone Number:
Type of Injury/Illness:
Type of Injury/Illness Code:
Part of Body Affected:
Part of Body Affected Code:
Did Injury/Illness Exposure Occur on Employer's Premises?:
Department of Location Where Accident or Illness Exposure Occurred:
All Equipment, Materials or Chemicals Employee was Using When Accident or Illness Exposure Occurred:
Specific Activity the Employee was Engaged in When the Accident or Illness Exposure Occurred:
Work Process the Employee was Engaged in When the Accident or Illness Exposure Occurred:
How Injury or Illness/Abnormal Health Condition Occurred. Describe the Sequence of Events and Include Any Objects or Substances that Directly Injured the Employee or Made the Employee Ill:
Cause of Injury Code:
Date Return(ed) to Work:
If Fatal, Give Date of Death:
Were Safeguards or Safety Equipment Provided?
Were They Used?
Physician/Health Care Provider (Name & Address):
Hospital (Name & Address):
Initial Treatment:
Witnesses Name & Phone:
Date Administrator Notified:
Date Prepared:
Preparer's Name & Title:
Phone Number:

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Baker, Jim
Casey, Bryan
Casey, Dod
Cohen, Neal
Cohn, Allan
Cook Kline, Stacia
Fox, Sue
Kibbe, Gene
Krell, Amir
Odekunle, Funlola
Orodeckis, Ed
Orodeckis, Eric
Orodeckis, Patrick
Quingert, Jack
Rosenberg, Henry
Rosenberg, Stephen
Rosenberg, Stewart H.
Schaftel, James
Stavrakas, Spyros
Summerfield, Alan
Summerfield, AAI, Jordan
Sutton(Kwiatowski), Tracy

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