EMPLOYEE 1.LAST NAME FIRST M.I. 2.SOCIAL SECURITY NUMBER 3.BIRTH DATE 4.HOME ADDRESS (NUMBER & STREET) CITY STATE ZIP COD E 5.TELEPHONE 6.SEX MALE FEMALE 7.MARITAL STATUS: SINGLE MARRIED DIVORCED WIDOWED EMPLOYER 9.POLICY NUMBER 10.NATURE OF BUSINESS (MANUFACTURING, ETC.) 11.OFFICE ADDRESS (NUMBER & STREET) CITY STAT E ZIP CODE 12.TELEPHONE ACCIDENT 13.DATE OF INJURY OR ILLNESS 14.TIME OF EVENT 16.DATE EMPLOYER NOTIFIED OF INJURY TIME EMPLOYEE BEGAN WOR 17.LAST DAY OF WORK AFTER INJURY 18.DATE OF RETURN TO WORK 19. 20.CLASS CODE ON PAYROLL REPORT 22.DEPARTMENT NUMBER 23.DID INJURY OCCUR ON EMPLOYER PREMISES? YES NO 24.ADDRESS OR LOCATION OF ACCIDENT C ITY COUNTY STATE ZIP CODE 25.WHAT WAS THE INJURY OR ILLNESS? Tell us the part of the body that was affected and how it was affected; be more specifi Examples: 26.PART OF BODY INJURED 27.FATAL YES NO 28.IF THE EMPLOYEE DIED, WHEN DID THE DEATH OCCUR? DATE OF DEATH 29.WAS EMPLOYEE TREATED IN AN EMERGENCY ROOM? YES NAME OF PHYSICIAN OR OTHER HEALT H CARE PROFESSIONAL ADDRESS 30.WAS EMPLOYEE HOSPITALIZED OVERNIGHT AS AN IN - PATIENT? YES IF HOSPITALIZED, HOSPITAL NAME ADDRESS 31.I CAUSE OF ACCIDENT 32. WHAT HAPPENED? Tell us how the injury occurred. Examples: 33. WHAT OBJECT OR SUBST ANCE DIRECTLY HARMED THE EMPLOYEE? Examples: If this question does not apply to the incident, leave it blank. 34. WHAT WAS EMPLOYEE DO ING JUST BEFORE THE INCIDENT OCCURRED? Describe the activity, as well as the tools, equipment, or material the empl oyee was using. Be specific. Examples: - 35. IF ANOTHER PERSON NO T IN COMPANY EMPLOY CAUSED ACCIDENT, GIV E NAME AND ADDRESS EMPLO 36.WAS WORKER IN YOUR EMPLOY WHEN INJURED? 38.WAS EMPLOYEE ON OVERTIME WHEN INJURED? 39.NUMBER OF DAYS PER WEEK USUALLY WORKED EMPLOYEEJURY WAGE DATA YES NO FROM HOURS PER DAY EMPLOYEE WORK THRU YES NO EMPLOYEE COMPANY IMPORTANT IF WORK LOSS IS EXPECTED TO EXCEED SEVEN CALENDAR DAYS, COMPLETE ITEMS 40 THRU 47 40.DATE OF LAST HIRE 41. WAS WORKER PAID FOR DAY OF INJURY? 42. WAS EMPLOYEE HIRED FOR PERMANENT EMPLOYMENT? YES NO 43.NUMBER OF MONTHS EMPLOYMENT AVAILABLE DURING THE YEAR HOUR DAY WEEK MONTH $ PER 45.IS EMPLOYEE FURNISHED VALUE LODGING BOARD BOTH $ 46.ACTUAL GROSS EARNINGS OF EMPLOYEE FOR THE 30 CALENDAR DAYS PRECEEDING INJURY (EXAMPLE: IF INJURED APRIL 8, GIVE EARNINGS FROM MARCH 9 THRU APRIL 7) 47.DOES EMPLOYEE CLAIM DEPENDENTS? YES NO IMPORTANT IF EMPLOYEE IS PAID OTHER THAN FIXED WEEKLY OR MO NTHLY SALARY, COMPLETE ITEMS 48 THRU 55 48.IF EMPLOYEE EARNS EXTRA PAY FOR OVERTIME, WHAT IS BASIS OF PAYMENT? PER HOUR 49.NUMBER OF HOURS OVERTI ME CONSIDERED NORMAL PER WEEK 50.GROSS WAGES OF EMPLOYEE DURING 12 MONTHS PRECEEDING INJURY 51.IF EMPLOYEE WORKED LESS THAN 12 MONTHS, SHOW GROSS WAGES FROM DATE OF HIRE THROUGH DAY PRIOR TO INJURY FROM THRU $ FROM THRU $ 52.DATE OF LAST WAGE INCREASE IF WITHIN 12 MONTHS PRIOR TO INJURY 53.WAGE BEFORE INCREASE $ 54.WAGE AFTER INCREASE $ 55.GROSS EARNINGS FROM DATE OF INCREASE THRU DAY PRIOR TO INJURY $ AUTHORIZED SIGNATURE DATE AUTHORIZED SIGNATURE TITLE NOTE TO EMPLOYER: one copy to the Industrial Commission within 10 days. one copy to your insurance carrier within 10 days.Keep one copy, for not less than five (5) years, as your supplementary record of injuries required by the Federal Occupational Safety and Health Act of 1970. The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted by Section 7(a)(2)(B) of the F ederal Privacy Act of disclosure of the social security number. The number is used as a means of identifying all the various reco rds in the Claims Division or Special Fund pertaining to an individual. The use of social security numbers is made necessary bec ause of the large number of persons who have similar names and birth dates, and whose identities can only be distinguished by t he social security number. THIS FORM APPROVED BY THE INDUSTRIAL COMMISSION OF ARIZONA FOR CARRIER USE FOR CARRIER USE ONLY INDUSTRIAL COMMISSION OF ARIZONA P.O. BOX 19070 PHOENIX, ARIZONA 85005-9070 FOR OSHA PURPOSES ONLY OSHA Case #: RECORDABLE INJURY NON-RECORDABLE INJURY OF INDUSTRIAL INJURY COMPLETE AND THIS REPORT WITHIN 10 DAYS FROM NOTICE OF ACCIDENT. FATALITIES MUST BE REPORTED WITHIN 24 HOURS. Employer must, on this form, notify his insurance carrier of every injury or disease suffered by an employee, fatal or otherwise, which is claimed to arise out of or in the course of employment. ARIZONA REVISED STATUTES 23-908 & 23-1061 CITY CITY STATE STATE ZIP CODE ZIP CODE YES NO NO NO American LegalNet, Inc. www.FormsWorkFlow.com