MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION P.O. Box 58 Jefferson City, MO 65102-0058 (To complete form, see attached instructions) REPORT OF INJURY EMPLOYER (NAME, ADDRESS, INCL ZIP CODE) CARRIER ADMINISTRATOR CLAIM NUMBER REPORT PURPOSE CODE JURISDICTION JURISDICTION CLAIM NUMBER GENERAL INSURED REPORT NUMBER EMPLOYERS LOCATION ADDRESS (IF DIFFERENT) LOCATION # SIC CODE EMPLOYER FEIN PHONE # CARRIER (NAME, ADDRESS & PHONE NO.) POLICY PERIOD CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO.) to CLAIMS ADMIN CHECK IF APPROPRIATE SELF INSURANCE CARRIER FEIN INSURANCE POLICY NUMBER ADMINISTRATOR FEIN CARRIER AGENT NAME & CODE NUMBER NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH SOCIAL SECURITY # DATE HIRED STATE OF HIRE EMPLOYEE ADDRESS (INCLUDE ZIP) SEX MALE FEMALE UNKNOWN MARITAL STATUS UNMARRIED SINGLE DIVORCED MARRIED SEPARATED UNKNOWN OCCUPATION JOB TITLE EMPLOYMENT STATUS PHONE # # OF DEPENDENTS NCCI CLASS CODE WAGE RATE PER TIME EMPLOYEE BEGAN WORK DAY WEEK AM PM MONTH OTHER # OF DAYS WORKED/WEEK FULL PAY FOR DAY OF INJURY? DID SALARY CONTINUE? YES YES NO NO DATE OF INJURY / ILLNESS TIME OF OCCURRENCE AM PM LAST WORK DATE DATE EMPLOYER NOTIFIED DATE DISABILITY BEGAN CONTACT NAME PHONE NUMBER TYPE OF INJURY ILLNESS PART OF BODY AFFECTED OCCURRENCE DID INJURY ILLNESS EXPOSURE OCCUR ON EMPLOYER'S PREMISES? YES NO TYPE OF INJURY/ILLNESS CODE PART OF BODY AFFECTED CODE ZIP CODE OF THE LOCATION WHERE THE 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 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 TO WORK IF FATAL, GIVE DATE OF DEATH WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? WERE THEY USED? YES YES NO NO TREATMENT PHYSICIAN HEALTH CARE PROVIDER (NAME & ADDRESS) HOSPITAL (NAME & ADDRESS) INITIAL TREATMENT 0 - NO MEDICAL TREATMENT 1 ­ MINOR: BY EMPLOYER 2 ­ MINOR CLINIC HOSPITAL 3 ­ EMERGENCY CASE 4 ­ HOSPITALIZED > 24 HOURS 5 ­ FUTURE MAJ. MED. LOST TIME ANTICIPATED OTHERS WITNESS (NAME & PHONE #) DATE ADMINISTRATOR NOTIFIED DATE PREPARED PREPARER'S NAME & TITLE PHONE NUMBER American LegalNet, Inc. www.FormsWorkFlow.com WC-1-EDI (02-16) AI NOTE: This form constitutes the detailed report of injury required by §287.380, RSMo, and rules applicable thereto. An injury that requires immediate first aid, but does not result in further medical treatment or lost time from work, need not be reported to the Division. Employers should report all injuries to their workers' compensation insurance carrier or third-party administrator (TPA) within five days of the date of the injury or within five days of the date on which the injury was reported to the employer by the employee, whichever is later. See §287.380, RSMo. If the employer has been granted self-insurance authority by the Division pursuant to §287.280, RSMo, and rules applicable thereto, please report all injuries to your TPA or Service Company to enable them to file this report with the Division. PRINT QUALITY: All reports of injury and supporting documents received by the Division will be processed electronically. All forms submitted to the Division MUST be of clear and legible quality. Handwritten forms will not be accepted. Computer generated forms shall use a minimum type size of 10 points. All documents not meeting the above criteria will be returned. TO BE ANSWERED ONLY IN CASE OF DEATH DATE OF DEATH EMPLOYEE'S DEPENDENTS NAME OF DEPENDENT RELATION TO EMPLOYEE ADDRESS OF DEPENDENT ADDRESS CITY STATE ZIP CODE Missouri Division of Workers' Compensation is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. TDD/TTY: 800-735-2966 Relay Missouri: 711 WC-1-EDI-2 (02-16) AI American LegalNet, Inc. www.FormsWorkFlow.com Data Element Dictionary for Hard Copy Report of Injury Data Element IAIABC Data Definition Missouri Notes This is the name the employer does business under followed by the FULL address including mailing address, city, state and zip code. This is the Standard Industrial Classification Code for the employer. SIC/NAICS codes can be found at www.census.gov/epcd/www/naics.html Mandatory Field M Employer (Name The name of the employer where the employee was & Address) employed at the time of the injury. Industry Code The code which represents the nature of the employer's business which is contained in the North American Industry Classification System Manual published by the Federal Office of Management and Budget. See implementation note below: The industry code selected should represent the primary nature of the employer's business. If the employer is assigned multiple industry codes, use the code that relates to the specific business operation for which the employee was employed at the time of the injury. The data element may contain an SIC code or NAICS Code. SIC code will be identified with the characters `SC' as the last two characters of the data element. If SC is not present, the code is presumed to be NAICS. Employer FEIN Report Purpose Code (RPC) The FEIN of the employer where the employee was employed at the time of the injury. M Must be the primary FEIN for the Employer listed above. M M Defines the specific purpose of the report being filed with the The Report of Injury that the employer is required to file with the state of Missouri. Division of Workers' Compensation (Division) through the insurance carrier or third party administrator (TPA). 00 = Original FROI 02=Change CO=Correction AQ=Acquired Report of Injury AU=Acquired Unallocated Report of Injury Claims Administrator's Number Jurisdiction Jurisdiction Claim Number Identifies a specific claim within a claim administrator's claims processing system. The governing body or territory whose statute applies. Number used by the organization adjusting the claim (insurance company, third party administrator, etc.). This must always be Missouri. The injury number assigned by the Division upon receipt of the First Report of Injury with all mandatory information provided. The reporting entity is to leave this field bla