MWCC - WORKERS' COMPENSATION - FIRST REPORT OF INJURY OR ILLNESS EMPLOYER (NAME & ADDRESS INCL ZIP) CARRIER/ADMINISTRATOR CLAIM NUMBER REPORT PURPOSE CODE JURISDICTION JURISDICTION CLAIM NUMBER INSURED REPORT NUMBER EMPLOYER'S LOCATION ADDRESS (IF DIFFERENT) SIC CODE EMPLOYER FEIN LOCATION # PHONE # CARRIER/CLAIMS ADMINISTRATOR CARRIER (NAME, ADDRESS & PHONE NO) POLICY PERIOD TO CHECK IF APPROPRIATE CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO) SELF INSURANCE CARRIER FEIN POLICY/SELF-INSURED NUMBER ADMINISTRATOR FEIN AGENT NAME & CODE NUMBER EMPLOYEE/WAGE NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH SOCIAL SECURITY NUMBER DATE HIRED STATE OF HIRE ADDRESS (INCL ZIP) SEX MALE (M) FEMALE MARITAL STATUS UNMARRIED/SINGLE/DIVORCED MARRIED OCCUPATION/JOB TITLE (U) EMPLOYMENT STATUS (F) UNKNOWN (U) (M) (S) PHONE # OF DEPENDENTS SEPARATED NCCI CLASS CODE UNKNOWN (K) RATE PER: DAY WEEK MONTH OTHER: #DAYS WORKED WEEK FULL PAY FOR DAY OF INJURY? DID SALARY CONTINUE? YES YES NO NO OCCURRENCE/TREATMENT TIME EMPLOYEE BEGAN WORK CONTACT NAME/PHONE NUMBER AM PM DATE OF INJURY/ILLNESS TIME OF OCCURRENCE AM LAST WORK DATE PM TYPE OF INJURY/ILLNESS PART OF BODY AFFECTED DATE EMPLOYER NOTIFIED DATE DISABILITY BEGAN DID INJURY/ILLNESS EXPOSURE OCCUR ON EMPLOYER'S PREMISES? YES NO COUNTY WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED TYPE OF INJURY/ILLNESS CODE PART OF BODY AFFECTED CODE ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED 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 CAUSE OF INJURY CODE DATE RETURN(ED) TO WORK IF FATAL, GIVE DATE OF DEATH WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? WERE THEY USED? HOSPITAL (NAME & ADDRESS) YES YES INITIAL TREATMENT NO MEDICAL TREATMENT (0) MINOR: BY EMPLOYER (1) MINOR CLINIC/HOSP (2) EMERGENCY CARE (3) NO NO PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS) WITNESSES (NAME & PHONE #) DATE ADMINISTRATOR NOTIFIED DATE PREPARED PREPARER'S NAME & TITLE HOSPITALIZED > 24 HRS (4) FUTURE MAJOR MEDICAL/ LOST TIME ANTICIPATED (5) PHONE NUMBER IAIABC IA-1 (8/01) SEE BACK FOR INSTRUCTIONS REPRINTED WITH PERMISSION OF IAIABC American LegalNet, Inc. www.FormsWorkFlow.com