First Report Of Injury Or Illness Form. This is a Idaho form and can be use in Claim Workers Compensation.
Tags: First Report Of Injury Or Illness, IA-1, Idaho Workers Compensation, Claim
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. WORKERS COMPENSATION – FIRST REPORT OFIndex No. OR ILLNESS INJURY : Employer (Name & Address incl. zip) Carrier/Administrator Claim Number Jurisdiction General : JUDICIAL SUBPOENA Location No. Employer’s Location Address (if different) -against- : Employer FEIN Phone No. : Carrier (Name, Address & Phone Number) Carrier/Claims Admin Jurisdiction Claim No. Calendar No. Insured Report No. Plaintiff(s) Sic Code Policy Period Claims Admin (Name, Address & Phone Number) : To Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Check if ... self insured Carrier FEIN Policy Number or Self-Insured Number Administrator FEIN THE PEOPLE OF THE STATE OF NEW YORK Agent Name & Code Number TO Legal Name (Last, First, Middle) Birth Date Address (Incl. Zip) Employee : Report Purpose Code Social Security Number Sex Male GREETINGS: Female Unknown No. of Dependents Phone Marital Status Unmarried/ Single/Div. Married Separated Unknown Date Hired State of Hire Occupation/Job Title Employment Status NCCI Class Code WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court Wage County of Rate Day Month # Days Worked/WK Full Pay for Date of Injury? Yes No located at # Hrs Worked per Day Week Other Did Salary Continue? Yes No $ in room , on the day of , 20 , at o'clock in the noon, and at any recessed Time Employee AM AM Date of Injury Date Disability or adjourned date, to testify and giveTime evidence as a witness in Last Work Date the part of the this action on Date Employer Notified Began Work PM or Illness Occurred Employer Contact Name/Phone Number Began PM Type of Illness/Injury Part of Body Affected Occurrence Did Injury/Illness Exposure Occur on Employer’s Yes Your failure to comply with this Premises? No Type of Illness/Injury Code Part Body Affected Code subpoena is punishable as a contempt of courtofand will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Department orof your where accident or illness exposure occurred All Equipment, Materials, or Chemicals Employee Using upon Occurrence result location failure to comply. Specific Activity Employee Engaged in at Time of Occurrence Witness, Honorable Work Process the Employee Was the Justices Time of Occurrence , one of Engaged in at of the Court in County, day of , 20 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. Date Returned to Work If Fatal, Date of Death Cause of Injury Code Were Safeguards or Safety Equipment Provided? Yes (Attorney must sign above and type name below) Were they used? Hospital (Name & Address) Other Treatment Physician/Health Care Provider (Name & Address) Attorney(s) for Signature of Injured Employee, or Signature on File, Date Witness to Accident (Name & Phone Number) Date Administrator Notified Preparer’s Name & Title 0 1 2 3 4 5 Yes N o N o Initial Treatment No Medical Treatment Minor: By Employer Minor Clinic/Hosp Emergency Care Hospitalized – 24 hr. Anticipated Major Med/Lost Time Office and P.O. Address Date Prepared Preparer’s Phone Number Filing this report is not an admission of liability. This report shall not be evidence of any fact stated herein in any proceeding in respect of the injury, illness or death on account of which this report is made. Idaho Industrial Commission, P.O. Box 83720, Boise, ID 83720-0041 IC Form IA-1 (2/98) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com