First Report Of Injury Form.doc

First Report Of Injury Form.doc - General IA-1 WORKERS...

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IA-1 WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS General Employer (Name & Address incl. zip) N/A Carrier/Administrator Claim Number Report Purpose Code Jurisdiction Jurisdiction Claim Number Insured Report Number N/A Employer’s Location Address (if different) N/A Location No. N/A Sic Code N/A Employer FEIN N/A Phone No. N/A Carrier/Claims Admin Carrier (Name, Address & Phone Number) N/A Policy Period Claims Admin (Name, Address & Phone Number) N/A N/A To N/A Check if self insured Carrier FEIN N/A Policy Number or Self-Insured Number N/A Administrator FEIN N/A Agent Name & Code Number N/A Employee/Wage Legal Name (Last, First, Middle) Date of Birth Social Security Number Date Hired State of Hire Address (Incl. Zip) Sex Marital Status Occupation/Job Title Male Unmarried/ Single/Div. Female Married Employment Status Unknown Separated Phone No. of Dependents Unknown NCCI Class Code Wage Rate $ Day Month # Days Worked/WK Full Pay for Date of Injury? Yes No Week Other # Hrs Worked per Day Did Salary Continue? Yes No Occurrence Time Employee Began Work AM Date of Injury or Illness Time Occurred AM Last Work Date Date Employer Notified Date Disability Began PM PM Employer Contact Name/Phone Number Type of Illness/Injury Part of Body Affected Did Injury/Illness Exposure Occur on Employer’s Premises? Yes Type of Illness/Injury Code Part of Body Affected Code No Department or 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 accident or illness exposure occurred.
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