ALL COPIES OF THIS FIRST REPORT MUST BE TYPED OR PRINTED Department of Labor Office of Workers' Compensation (OWC) 4425 N. Market Street Wilmington, DE 19802 Telephone 302-761-8200 1. EMPLOYEE: FIRST STATE OF DELAWARE FIRST REPORT OF OCCUPATIONAL INJURY OR DISEASE OWC Case File No. ALL INFORMATION IS REQUIRED, unless not applicable where "if applicable" is noted. MIDDLE LAST 2. EMPLOYEE SOCIAL SECURITY NO. 4. MALE FEMALE 6. DATE OF BIRTH 7. AGE 8. WAGE 5. EMPLOYEE PHONE NUMBER (INCLUDING AREA CODE) 3. ADDRESS ­ INCLUDE COUNTY AND ZIP CODE 9. WEEKLY HOURS WORKED 12. HOW LONG EMPLOYED / / 11. DEPARTMENT OR DIVISION REGULARLY EMPLOYED 14. PERSON MAKING OUT THIS REPORT 16. EMPLOYER PHONE # (INCLUDE AREA CODE) 18. NATURE OF BUSINESS ­ TYPE OF MFG., TRADE, CONSTURCTION, SERVICE, ETC. 20. WORKERS' COMP. INS. CARRIER PHONE #, (INCLUDING AREA CODE 22. POLICY NUMBER / CARRIER CASE NUMBER: 10. OCCUPATION (REGULAR) 13. EMPLOYER: 15. ADDRESS ­ INCLUDE COUNTY AND ZIP CODE 17. MAILING ADDRESS ­ IF DIFFERENT THAN ABOVE 19. WORKERS' COMPENSATION INSURANCE CARRIER 21. WORKERS' COMP. INSURANCE CARRIER ADDRESS / 23. THIRD PARTY ADMINISTRATOR (TPA), IF APPLICABLE 24. TPA ADDRESS ­ INCLUDE CITY STATE AND ZIPCODE 28. IF EMPLOYEE BACK TO WORK GIVE DATE DATES: 25. DATE OF REPORT 26. DATE OF INJURY 27. NORMAL STARTING TIME 29. AT SAME WAGE? / / / / / / 30. IF FATAL INJURY, GIVE DATE OF DEATH AM PM 31. DATE EMPLOYER KNEW OF INJURY / / / / 32. DATE DISABILITY BEGAN YES NO 33. LAST FULL DAY PAID-DATE / / / / INJURY OR DISEASE: 34. DESCRIBE THE INJURY/ILLNESS AND PART OF BODY AFFECTED. 35. SPECIFY THE DEPARTMENT WHERE INCIDENT OCCURRED AND THE WORK PROCESS INVOLVED. OCCURRENCE: 36. LIST THE EQUIPMENT, MATERIALS, AND CHEMICALS EMPLOYEE USED WHEN THE INCIDENT OCCURRED, E.G. ACETYLENE. 37. DESCRIBE THE EMPLOYEE'S ACTIVITY AT THE TIME OF INJURY OR ILLNESS, E.G. LIFTING A PATIENT. 38. DESCRIBE HOW THE INJURY/ILLNESS OCCURRED. 39. NAME OF PHYSICIAN (IF APPLICABLE) 41. HOSPITAL (IF APPLICABLE) 40. PHYSICIAN'S ADDRESS 42. HOSPITAL ADDRESS 1. 2. 3. 4. DISTRIBUTION OF THIS REPORT (1 original and 3 copies) ORIGINAL MUST BE SENT IMMEDIATELY TO THE WORKERS' COMPENSATION INSURANCE CARRIER. COPY TO THE OFFICE OF WORKERS' COMPENSATION (use the address at the top left of this form) EMPLOYER'S COPY ­ RETAIN AS RECORD EMPLOYEE'S COPY American LegalNet, Inc. www.FormsWorkFlow.com WORKERS' COMPENSATION IMPORTANT THINGS TO DO IN CASE OF INJURY THE EMPLOYER SHOULD: 1. Provide all necessary medical, surgical and hospital treatment from the date of accident. 2. Every employer shall keep a record of all injuries received by employees and make a report within 10 days thereof in writing to the Office of Workers' Compensation 3. Ascertain the average weekly wages of the employee and provide compensation in accordance with the provisions of the law, for disability beyond the third day after the accident. All agreements as to compensation must be submitted to the Office of Workers' Compensation for approval. THE EMPLOYEE SHOULD: 1. Immediately notify the employer in writing of accidental injury or occupational disease and request medical services. Failure to give notice or to accept medical services may deprive the employee of the right to compensation. 2. Give promptly to the employer, directly or through a supervisor, notice of any claim for compensation for the period of disability beyond the third day after the accident. In case of fatal injuries, notice must be given by one or more dependents of the deceased or by a person on their behalf. 3. In case of failure to reach an agreement with the employer in regard to compensation under the law, file application with the Industrial Accident Board for a hearing on the matters at issue within two years of the date of accidental injury or one year of knowledge of the diagnosis of an occupational disease or an ionizing radiation injury. All forms can be obtained from the Office of Workers' Compensation. Document 60 07 02 11 12 01 American LegalNet, Inc. www.FormsWorkFlow.com