WC First Report of Injury or Illness

General

Employer Name

Carrier/Admin Claim Number

Employer Address Line 1

OSHA Log Number

Employer Address Line 2

Report Purpose Code

City

State

ZIP

Jurisdiction

Jurisdiction Claim Number

Insured Report Number

Location (if different from above)

Location Address

Location Number

Industry Code

Employer FEIN

Phone Number

Carrier / Claims Administrator

Carrier (Name, Address & Phone)

Claims Administrator (Name, Address & Phone)

Policy Period — From

Policy Period — To

Self-Insurance

Carrier FEIN

Policy / Self-Insured Number

Administrator FEIN

Agent Name and Code Number

Employee & Wage

Employee Name (Last, First, Middle)

Date of Birth

Address Line 1

Social Security Number

Address Line 2

Date Hired

City

State

ZIP

State of Hire

Sex

Male Female Unknown

Marital Status

Single Married Separated Unknown

Occupation / Job Title

Employment Status

NCCI Class Code

Claimant May Need an Interpreter

Yes No

Language

Employee Phone

Number of Dependents

Wage

Rate

Per

Day Week Month Other

Number of Days Worked / Week

Full Pay For Day of Injury

Yes No

Did Salary Continue?

Yes No

Occurrence & Treatment

Time Employee Began Work

AM / PM

AM PM

Date of Injury / Illness

Time of Occurrence

AM / PM

AM PM

Last Work Date

Date Employer Notified

Date Disability Began

Contact Name / Phone

Type of Injury / Illness

Part of Body Affected

Did Injury Occur on Employer's Premises?

Yes No

Type of Injury / Illness Code

Part of Body Affected Code

Department or Location Where Accident Occurred

All Equipment, Materials, or Chemicals in Use

Specific Activity Employee Was Engaged In

Work Process Employee Was Engaged In

How Injury / Illness Occurred (sequence of events, objects/substances that caused harm)

Cause of Injury Code

Date Returned to Work

If Fatal, Date of Death

Were Safeguards or Safety Equipment Provided?

Yes No

Were They Used?

Yes No

Physician / Health Care Provider (Name & Address)

Hospital (Name & Address)

Initial Treatment

No Medical Treatment Minor: By Employer Minor: Clinic / Hospital Emergency Care Hospitalized – 24 hrs Future Major Medical / Lost Time Anticipated

Other

Witnesses (Name & Phone Number)

Date Administrator Notified

Date Prepared

Preparer's Name & Title

Phone Number