MAIL TO: WORKERS' COMPENSATION INSURER Employee Social Security Number Employer UI Account Number EMPLOYER REPORT Employer Federal ID Number OF INJURY/ILLNESS This report is completed by the Employer for each injury/illness identified by them or their employee as occupational. A copy is to be provided to the employee and the insurer immediately. PURPOSE OF REPORT: (Check all that apply) __ More than 7 days of disability __ Possible dispute __ Injury resulted in death __ Lump Sum Compromise/Settlement __ Amputation or disfigurement __ Other 1.Date ofReport MM/DD/YY 2. Date / time of Injury MM/DD/YY Time __AM __PM 6. If Fatal Injury, Give Date of Death MM/DD/YY 3. Normal Starting Time Day of Accident __ AM __ PM 7. Date Employer Knew of Injury MM/DD/YY 4. If Back toWork Give date MM/DD/YY 5. At same wage? __Yes __ No Middle 8. Date Disability began MM/DD/YY DO NOT WRITE IN THIS COLUMN 12. Employee Phone # ( ) 11. __ Male __ Female 13. Address and Zip Code 16. Date of Birth 19. Place of Injury-Employer's Premises ? __ Yes __ No 17. Occupation Date Received Naics:. State-Parish 18. Dept/Division Employed Last 9. Last Full Day Paid MM/DD/YY 14. Parish of Injury 10. Employee Name First 15. Date of Hire __ Medical only ( DO NOT mail copy to OWCA ) Occupation 20. If No, Indicate Location-Street, City, Parish and State Nature 21. What work activity was the employee doing when the injury occurred? (Give weight, size and shape of materials or equipment involved). Explain what employee was doing with them. Indicate if correct procedures were followed. Part of Body Source Event NCCI 22. What caused injury to happen? (Describe fully the events which resulted in injury or disease. Explain what happened and how it happened. Name any objects or substances involved and explain how they were involved. Give full details on all factors which led to or contributed to this injury or illness.) 23. Part of Body Injured and Nature of Injury or Illness (ex. left leg; multiple fractures) 24. If Occ. Disease-Give Date Diagnosed 25. Physician and Address 26. If Hospitalized, give name & address of facility 27. Employer's Name 28. Person Completing This Report - Please print 29. Employer's Address and Zip Code 30. Employer's Telephone Number ( 31. Employer's Mailing Address-If Different From Above 33. Wage Information (optional) Address: Employee was paid __ Daily LWC-WC-1007 Insurer Name: Rev: 07/08 Phone: ) 32. Nature of Business-Type of Mfg., Trade, Construction, Service, etc. __ Weekly __ Monthly __ Other. T he average weekly wage was $ per week. Address: Insurer's Administrator or Representative: Phone: American LegalNet, Inc. www.FormsWorkflow.com