MN Department of Labor and Industry Workers' Compensation Division (651) 284-5032 or 1-800-342-5354 First Report of Injury See Instructions on Reverse Side PRINT IN INK or TYPE ENTER DATES IN MM/DD/YYYY FORMAT 1. EMPLOYEE SOCIAL SECURITY # 2. OSHA case # 3. Time employee began work on date of injury am pm 7. EMPLOYEE Name (last, suffix, first, middle) 8. Gender M 10. Home address City State Zip Code F 9. Marital status Married Unmarried 12. Date of birth 6. Date of death am FR 1 0 DO NOT USE THIS SPACE 4. DATE OF CLAIMED INJURY 5. Time of injury pm # of dependents (if death is related to injury) test 11. Home phone # 14. Occupation 13. Date hired 16. Apprentice Yes No Part time Volunteer 15. Regular department 21. Employment status (check all that apply) 17. Average weekly wage 18. Rate per hour 19. Hours per 20. Days per Normal work schedule Sun - Sat S M T W T F S day week Full time Seasonal 22. Tell us how the injury/illness occurred, what the employee was doing before the incident (give details), and what the injury/illness was. Examples: "Worker was driving lift truck with a pallet of boxes when the truck tipped, pinning worker's left leg under drive shaft." "Worker developed soreness in left wrist over time from daily computer key entry." 23. What was the injury or illness (include the part(s) of body)? Examples: chemical burn left hand, broken left leg, carpal tunnel syndrome in left wrist. 24. What tools, equipment, machines, objects, or substances were involved? Examples: chlorine, hand sprayer, pallet lift truck, computer keyboard. 25. Did injury occur on employer's premises? Yes No Name and address of the place of the occurrence 26. Date of first day of any lost time 28. Date employer notified of injury 30. Return to work date 27. Employer paid for lost time on day of injury (DOI) Yes No No lost time on DOI 29. Date employer notified of lost time 31. RTW same employer No 32. RTW with restrictions Yes Minor clinic/hospital No 33. Treating physician (name) 35. Certified Managed Care Organization (if any) 36. EMPLOYER Legal name 38. Mailing address City State Zip Code Yes 34. Extent of medical treatment (check all that apply) None Minor on-site by employer's medical staff Emergency room Hospitalization more than 24 hours Future major medical anticipated 37. EMPLOYER DBA name (if different) 39. Employer FEIN 40. Unemployment ID # 41. Employer's contact name and phone # 43. Witness (name and phone) - if more than 1 attach a separate sheet 42. Physical address (if different) City 46. INSURER name State Zip Code 44. NAICS code 45. Date form completed 51. CLAIMS ADMIN COMPANY (CA) name (check one) Insurer TPA 47. Insured legal name and FEIN 48. Policy # (including effective dates) or self-insured certificate # 49. Insurer FEIN 55. To be completed by the CA: MN FR01 (3/16) 50. Date insurer received notice 52. CA address City 53. CA FEIN State Zip Code 54. CA claim # Claim type code: Type of loss code: Late reason code: Salary paid in lieu of comp? Death result of injury? American LegalNet, Inc. www.FormsWorkFlow.com Employer: Send copies to Insurer (or Workers' Compensation Division if no insurer), employee, and employee's union (if applicable) GENERAL INSTRUCTIONS TO THE EMPLOYER Employers, not employees, are responsible for completing this form. The information is needed to determine liability and entitlement to benefits. You must file this form with your insurer, and give a copy to the employee and the employee's local union office. You are required to provide the employee with a copy of the Employee Information Sheet, which is available on the Department of Labor and Industry's web site at www.dli.mn.gov. Filing this form is not an admission of liability. You must report a claim to your insurer whenever anyone believes that a workrelated injury or illness that requires medical care or where lost time from work has occurred. If the claimed injury wholly or partially incapacitates the employee for more than three calendar days, the claim must be made on this form and reported to your insurer within ten days. Your insurer may require you to file it sooner. Failure to file within the ten days may result in penalties. It is important to file this form quickly to allow your insurer time to investigate the claim. Your insurer will report the injury to the Department of Labor and Industry (Department), when necessary. Self-insured employers have 14 days to report the injury to the Department, when necessary. If the claim involves death or serious injury (including injuries that later result in death), you must notify the Department and your insurer within 48 hours of the occurrence. The claim can be reported initially to the Department by telephone (651-284-5041), fax (651-284-5731), or personal notice. The initial notice must be followed by the filing of this form with the Department within seven days of the occurrence, at P.O. Box 64221, St. Paul, MN 55164-0221. SEND THIS FORM TO YOUR INSURER IMMEDIATELY � DO NOT WAIT FOR THE DOCTOR'S REPORT SPECIFIC INSTRUCTIONS TO THE EMPLOYER ON COMPLETING THIS FORM � � � � � � � � � � � � � Item 2: OSHA case #. Fill in the case number from the OSHA 300 log. This form contains all items required by the OSHA form 301. Items 17-21: Fill in all the wage information. If the employee does not work a regularly scheduled work week, attach a 26 week wage statement so your insurer can calculate the appropriate average weekly wage. Attach a separate sheet giving the weekly value of any meals, lodging, or 2nd income paid to the employee. Item 20: Fill in the average number of days per week that the employee works. Also include their normal work schedule, Sunday Saturday, by checking the appropriate boxes. If the employee's work schedule fluctuates from week-to-week, leave the boxes blank. Items 22-24: Be as specific as possible in describing: the events causing the injury; the nature of the injury (cut, sprain, burn, etc.), and the part(s) of body injured (back, arm, etc.); and the tools, equipment, machines, objects or substances involved. Item 26: Fill in the first day the employee lost any time from work (including time lost for medical treatment), even if you paid the employee for the lost time. Item 27: Check the appropriate box to indicate if there was lost time on the date of injury and whether you paid for that lost time. Item 28: Fill in the date you first became aware of the injury or illness. Item 29: Fill in the date you became aware that