WORKERS COMPENSATION ­ FIRST REPORT OF INJURY OR ILLNESS EMPLOYER (NAME & ADDRESS INCL ZIP) CARRIER/ADMINISTRATOR CLAIM NUMBER JURISDICTION INSURED REPORT NUMBER EMPLOYER'S LOCATION ADDRESS (IF DIFFERENT) INDUSTRY CODE EMPLOYER FEIN LOCATION # PHONE # OSHA LOG CASE # REPORT PURPOSE CODE JURISDICTION CLAIM NUMBER CARRIER/CLAIMS ADMINISTRATOR CARRIER (NAME, ADDRESS, & PHONE #) POLICY PERIOD TO CHECK IF APPROPRIATE SELF INSURANCE CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO) CARRIER FEIN POLICY/SELF-INSURED NUMBER ADMINISTRATOR FEIN EMPLOYEE/WAGE NAME (LAST, FIRST, MIDDLE) ADDRESS (INCL ZIP) DATE OF BIRTH SEX M MALE SOCIAL SECURITY NUMBER MARITAL STATUS U M S K UNMARRIED SINGLE/DIVORCED DATE HIRED STATE OF HIRE OCCUPATION/JOB TITLE EMPLOYMENT STATUS PHONE FEMALE F U UNKNOWN # OF DEPENDENTS MARRIED SEPARATED UNKNOWN NCCI CLASS CODE YES YES NO NO RATE PER: DAY WEEK MONTH OTHER: DAYS WORKED/WEEK FULL PAY FOR DAY OF INJURY? DID SALARY CONTINUE? OCCURRENCE/TREATMENT TIME EMPLOYEE BEGAN WORK AM PM CONTACT NAME/PHONE NUMBER DATE OF INJURY/ILLNESS TIME OF OCCURRENCE ( ) CANNOT BE DETERMINED TYPE OF INJURY/ILLNESS AM PM PART OF BODY AFFECTED LAST WORK DATE DATE EMPLOYER NOTIFIED DATE DISABILITY BEGAN DID INJURY/ILLNESS/EXPOSURE OCCUR ON EMPLOYER'S TYPE OF INJURY/ILLNESS CODE PART OF BODY AFFECTED CODE PREMISES? YES NO DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS OCCURRED 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(ED) TO WORK IF FATAL, GIVE DATE OF DEATH WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? WERE THEY USED? HOSPITAL OR OFF SITE TREATMENT (NAME & ADDRESS) YES NO PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS) NO YES INITIAL TREATMENT 0 1 2 3 4 5 NO MEDICAL TREATMENT MINOR: BY EMPLOYER MINOR CLINIC/HOSP EMERGENCY CARE HOSPITALIZED > 24 HOURS FUTURE MAJOR MEDICAL/ LOST TIME ANTICIPATED OTHER WITNESSES (NAME & PHONE #) DATE ADMINISTRATOR NOTIFIED DATE PREPARED PREPARER'S NAME & TITLE PHONE NUMBER FORM IA-1(r 1-1-02) SEE BACK FOR IMPORTANT INFORMATION IAIABC 2002 American LegalNet, Inc. www.USCourtForms.com AWCC Form 1 (Employer's First Report of Injury or Illness) Ark. Code Ann. § 11-9-529 allows employers 10 days to report injuries. Those involving either more than 7 days of lost time or indemnity payments require Form 1. Also, a Form 1 is required for all controversions including a medical-only case. Self-insured employers file Form 1 with the AWCC; other employers send it to their insurance representatives. Employers do NOT fill in the shaded areas. On Form 1, employers/carriers must: 1. In the Occurrence Section list the date the employer first knew of the injury. The 10 days to report begin either on the date of disability or the date the employer was notified, whichever date is later. Give the name of the carrier. An insurance agency or third party administrator should be listed in the Preparer's Section. A carrier can pre-print its name and address in the Carrier Section to help clients properly report. Specify the carrier Federal Employer Identification Number (FEIN) in the Carrier Section. Type or print in ink. An illegible, incomplete Form 1 will be returned. 2. 3. 4. Neglect of Form 1: Late employee benefits, exposing employers to fines. Lack of Form 1: Delays in insurance investigation. General inquiries on Form 1 can be answered by the AW CC Supp ort Ser vices Division. Questions on a specific Form 1 may be directed to the Research and Statistics Section, which processes the accident reports. (1-800-6 22-447 2 or 501 -682-393 0). Ark. Code Ann. §11-9-10 6(a): "Any p erson or entity who willfully and kno wingly make s any m aterial false statement or representation, who willfully and knowingly omits or conceals any material information, or who willfully and knowingly employs any device, sche me, or artifice for the purpose of: obtaining any benefit or paym ent; defeating or wrongfully increasing or wrongfully decreasing any claim for benefit or payment; or obtaining or avoiding workers' compensation coverage or avoiding payment of the proper insurance premium, or who aids and abets for any of said p urposes, und er this chapter shall be guilty of a Class D felo ny. Fifty percent (50%) of any criminal fine imposed an d collected under .... this section shall be paid and allocated in accord ance with app licable law to the Death and Permanent Total Disability Trust Fund administered by the Workers' Compensation Commission." (Revised 1-1-2001) American LegalNet, Inc. www.USCourtForms.com EMPLOYER'S INSTRUCTIONS DO NOT ENTER DATA IN SHADED FIELDS DATES: Enter all dates in MM/DD/YY format. INDUSTRY CODE: This is the code which represents the nature of the employer's business, which is contained in the Standard Industrial Classification Manual or the North American Industry Classification System, published by the Federal Office of Management and Budget. CARRIER: The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer of the claimant. CLAIMS ADMINISTRATOR: Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administering the claim. AGENT NAME & CODE NUMBER: Enter the name of your insurance agent and his/her code number if known. This information can be found on your insurance policy. OCCUPATION/JOB TITLE: This is the primary occupation of the claimant at the time of the accident or exposure. EMPLOYMENT STATUS: Indicate the employee's work status. The valid choices are: Full-Time On Strike Unknown Part-Time Disabled Apprenticeship Full-Time Not Employed Retired Apprenticeship Part-Time Volunteer Seasonal Piece Worker DATE DISABILITY BEGAN: The first day on which the claimant originally lost time from work due to the occupation injury or disease or as otherwise designated by statute. CONTACT NAME/PHONE NUMBER: Enter the name of the individual at the employer's premises to be contacted for additional information. TYPE OF INJURY/ILLNESS: Briefly describe the nature of the injury or illness, (eg. Laceratio