Iowa Workers' Compensation ­ FIRST REPORT OF INJURY OR ILLNESS Claim Administrator Name: CLAIM ADMIN Mailing Address, City, State, & Postal Code: Jurisdiction Code______________ Claim Representative Business Phone Number: Claim Administrator Claim Number: Claim Administrator FEIN: Jurisdiction Claim Number_______________ Insurer Name (if different than claim administrator): Insurer FEIN: Claim Type Code: Insured Report Number: Employer Type Code: __ Employer (E) __ Lessor (L) Employer UI Number: Employer Name: Employer FEIN: EMPLOYER Physical Address, City, State, & Postal Code: Mailing Address, City, State, & Postal Code: Industry Code: Insured Location Number: Nature of Business: Insured Name (parent company if different than employer): POLICY Insured FEIN: Insured Postal Code: Employer Contact Name and Business Phone Number: Policy/Contract Number: Coverage Effective Date: Coverage Expiration Date: Self Insurance License/ Certificate Number: Employee Name (First, Middle, Last, & Suffix): Date of Birth: Gender: __ Male (M) __ Female (F) Tax Filing Status (check one): ____ Single (A) ____ Single/Head of Household (B) ____ Married/Filing Joint (C) ____ Married/Filing Separate(D) Marital Status: (check one) ___ Unmarried (U) ___ Married (M) ___ Separated (S) Employee's Authorization to Release the Following: Medical Records Social Security Number __ yes __ yes __ no __ no Mailing Address, City, State, & Postal Code: Date of Hire: Educational Level (grade completed): _______ [GED = 12] Employment Status (check one): EMPLOYEE Phone Number (include area code): Occupation Description: ____ Piece Worker ____ Volunteer ____ Seasonal ____ Apprenticeship/Full-Time Manual Classification Code: Department Where Regularly Worked: ____ Apprenticeship/Part-Time ____ Regular Employee/Full-Time ____ Part-Time ____ Other Employee ID Number (check one): ID # ______________________ ____ Social Security Number ____ Employment VISA Number ____ Passport Number ____ Green Card ____ Employee ID Assigned by Jurisdiction ___ yes ___ yes ___ no ___ no Average Wage $ ___________ (check one): WAGE ___ hourly ___ bi-weekly ___ daily ___ annual ___ semi-monthly ___ weekly ___ monthly Salary Continued In Lieu of Compensation: Full Wages Paid for Date of Injury: Employee Number of Dependents: __________ Employee Number of Exemptions: ___________ (check one) Number of Days Regularly Worked Per Week: _______ _____________________ Date of Injury _____________________ Date Employer Had Knowledge of the Injury _____________________ Date Claim Administrator Had Knowledge of the Injury _____________________ Initial Date Last Day Worked _____________________ Initial Return to Work Date (if applicable) _____________________ Employee Date of Death (if applicable) _____________________ Time of Injury _____________________ Time Employee Began Work Pre-Existing Disability Code: ACCIDENT/INJURY ___ Yes ___ No ___ Unknown Accident Premises Code: ___ Employer (E) ___ Lessee (L) ___ Other (X) Accident Site Organization Name: Discontinued Fringe Benefits: $_____________ Describe the nature of the injury. (ex. amputation, burn, cut, fracture): ___ Entitled ___ Withholding Part(s) of body directly affected by the injury or illness. (ex. hand, arm, circulatory system): Describe the events that caused the injury. (ex. fell, operating machinery, chemical exposure): Name the object or substance that directly injured the employee. (ex. knife, floor, acid, oil): Accident Site Street, City, State, & Postal Code: Specify activity the employee was engaged in when the event occurred. (ex. cutting metal plate for flooring) Indicate if activity was part of normal duties: Accident Location Narrative (if no street address): Accident Site County/Parish: Initial Treatment Code (check one): ___ no medical treatment (0) ___ minor/on-site treatment (1) ___ clinic/hospital visit (2) ___ emergency care (3) ___ hospitalization > 24 hours (4) ___ future medical treatment/lost time anticipated (5) Preparer's Name & Title: Witness Name & Business Phone Number: Initial Medical Provider Name: Managed Care Organization Name or ID Number: MEDICAL Initial Medical Provider Physical Address, City, State, & Postal Code: ICD Primary Diagnostic Code (if known): Preparer's Company Name: Phone Number: Date: © IAIABC FORM 1.2 (12/98) American LegalNet, Inc. www.FormsWorkFlow.com !!!!!!!!!!!!!! " # !!!!!!!!!!!!!!! tttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttt tttttttttt ttttttttt tt tttttttttt ttttttt t tttttttttt tttttttttt ttttttttttttttttttttttttt tttttttttttttttttttttttttttttttttt tttt ttttttttt tttttttttttttttttttttttttt ttttt ttttttttttttt ttttttttttttttttt tttt tttttttttttttttttttttttttttt tt tttttttttttttttttttttttttttttttt tttt ttttttttttttttttt tttttttttttttttt ttttttttttt tt ttttttt tttttttttttttttttttt ttttttttttttttttttttttttt tttttttttt ttttt ttttttttttttttttt tttt tttt ttttt ttt ttttt ttt ttt t t tttt ttt tt tt ttttt tttt ttttttttt ttt ttt ttttttttt tttt tt tttttt ttt ttt ttttt tttt ttttt ttttt ttt t tt tt tttt tttttttttttt ttttttttttttttttttttttttttttttttttttttttttttttt tttttttt ttt tttttttttttttt ttt tttt tttttttttttttttttttttttttttttttttt tttttttttttttttttttttttttttttttt tt ttt tttttttttttt ttttttttttttttttt tt ttttt t tttttttttttttt tttttt ttttt ttttttttttttttttt tttttttt tt ttttttttttttttttttt ttttttt tttttttttttttt ttttttttt t tt tt ttt tttt tttt t tt tttttttttttt tttt tttttt ttt tttttt tt tttttt tttttttt ttt tt t tttttttt tttttt ttttttttttt ttttt t tt tttttttttttt tttt ttttttttt t tt tttttt tt ttttt tttt tttttt ttt tttttttt ttt t tt tttttt tt tttttttt tt ttttttt tt ttttttt t tttt ttt tttttttttttt ttt t tt ttttt ttttttt tttt ttt t tt ttttt t ttttt ttt t tt ttttttttt ttt tt ttttttt ttt ttttttt ttt ttttt tttttttttt ttt t tt tttttttt ttttttttt tt ttttttttttttttttttttttttt ttttt tt tttt ttttttttttttttttttttttttttttt tttttttttttttttt ttttttttttttttt ttttttttttttttttttttt ttttttttttttttttttttttttttttttttttttttttttttttttt tttttttttt ttttt t ttttttttttttttttttttttttttttttttt ttttttt t tttttttttttttt tttttttttttttttttttttttttttttttttt ttt ttttttttttttttt tttttttttttttttttttttttttt ttt tttttttt tttttttttttttttttttttttt tttt ttttttttt tttttttttt ttttttttttttttttttttttttttttttt t t t t ttttttttttt ttt tttttttttttttttttttttt ttt t tttttttttttttttttttttt tttttt ttttt tt tttttttttttttttttttttt ttttttt tttt ttttt ttttttttt tttttttt#ttttttt tttttttttttttttttttttttttttttttttttttttttttttt ttt t tttttttttttttttttttttt tttttt ttt