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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:
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:
Employee/Wage
Name (Last, First, Middle):
Address (Include Zip):
Phone:
Date of Birth:
Sex:
Marital Status:
# Dependents:
Social Security Number:
Date Hired:
State Hire:
Occupation/Job Title:
Employment Status:
NCCI Class Code:
Rate:
  Per:
Average Weekly Wages:
# Days Worked/Week:
Full Pay for Day of Injury?
Did Salary Continue?
Occurrence/Treatment
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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