WORKERS COMPENSATION ­ FIRST REPORT OF INJURY OR ILLNESS Employer (Name & Address incl. zip) Carrier/Administrator Claim Number Jurisdiction General Jurisdiction Claim No. Report Purpose Code Insured Report No. Employer's Location Address (if different) Location No. NAICS Code Employer FEIN Phone No. Carrier (Name, Address & Phone Number) Carrier/Claims Admin Policy Period To Check if self insured Claims Admin (Name, Address & Phone Number) Carrier FEIN Agent Name & Code Number Legal Name (Last, First, Middle) Address (Incl. Zip) Policy Number or Self-Insured Number Administrator FEIN Birth Date Sex Male Social Security Number Marital Status Unmarried/ Single/Div. Married Separated Unknown Date Hired Occupation/Job Title State of Hire Employee Phone Female Unknown No. of Dependents Employment Status NCCI Class Code Wage Rate $ Time Employee Began Work AM PM Day Week Date of Injury or Illness Month Other Time Occurred # Days Worked/WK # Hrs Worked per Day Full Pay for Date of Injury? Did Salary Continue? Date Employer Notified Yes Yes Date Disability Began No No AM PM Last Work Date Employer Contact Name/Phone Number Did Injury/Illness Exposure Occur on Employer's Premises? Yes No Type of Illness/Injury ype of Illness/Injury Code Type of Illness/Injury Code Part of Body Affected Part of Body Affected Code Occurrence Department or location where accident or illness exposure occurred All Equipment, Materials, or Chemicals Employee Using upon Occurrence Specific Activity Employee Engaged in at Time of Occurrence Work Process the Employee Was Engaged in at Time of Occurrence Cause of Injury Code Yes Yes 0 1 2 3 4 5 Initial Treatment No Medical Treatment Minor: By Employer Minor Clinic/Hosp Emergency Care Hospitalized ­ 24 hr. Anticipated Major Med/Lost Time No No 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 Were Safeguards or Safety Equipment Provided? Were they used? Physician/Health Care Provider (Name & Address) Treatment Hospital (Name & Address) Other Signature of Injured Employee, or Signature on File, Date Date Administrator Notified Date Prepared Witness to Accident (Name & Phone Number) Preparer's Name & Title 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 (08/2013) American LegalNet, Inc. www.FormsWorkFlow.com