First Report Of Injury And Occupational Disease
First Report Of Injury And Occupational Disease Form. This is a Montana form and can be use in Workers Compensation.
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First Report of Injury or Occupational Disease Instructions Workers’ compensation insurance is a state-required insurance, which provides medical benefits, wage compensation and rehabilitation to workers injured on the job. Severe penalties can be assessed against an uninsured employer. Neither general liability nor health and accident insurance policies are substitutes for workers’ compensation insurance. The worker and employer may complete this form together or they may each submit a separate form. Injured Worker’s Instructions Workers have two reporting requirements: 1) Notify your employer of an on-the-job injury within 30 days of its occurrence and 2) Complete this form as a claim for compensation. The form must be signed and submitted to the employer’s insurer or the Department of Labor and Industry within 12 months of the accident, however the insurer may waive the time requirement up to 24 months. The form must be submitted for all injuries in order to protect your right to benefits in the event a seemingly minor injury develops into a more serious condition. Complete a report of the injury Be thorough in completing all areas except the gray shaded areas. It is important to you that we have complete information. Use extra sheets of paper if needed. Type or print with a ballpoint pen. To ensure that workers’ compensation systems will not be disrupted, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, 42 USC 1301, et. seq., permits the disclosure of protected health care information pursuant to the provisions of state laws regarding workers’ compensation. 45 CFR 165.512(1) states: “Standard: Disclosures for workers’ compensation: A covered entity may disclose protected health information as authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault. Employer’s Instructions Montana law requires employers to complete this form within six days after notice of every on-the-job injury and/or occupational disease (OD) by a worker. Ensure all areas are completed except the gray shaded areas, which your insurer will complete. It is important that we have complete information. Type or print with a ballpoint pen. If you are completing with WORD software, you may tab through the fields. If the injured worker is available to do so, they may file a claim for workers’ compensation by completing and signing their portions of this form. You may then complete the employer section. Send the original immediately to your workers’ compensation insurer. If you don’t know whom your insurer is, contact the Montana Department of Labor and Industry (see below). SEND THIS FORM WITHIN THE 6-DAY LIMIT EVEN IF THE WORKER IS NOT AVAILABLE TO SIGN. This form must be submitted even if the employer questions whether or not the reported injury and/or OD are job-related. Additional sheets of paper may be attached, if needed to fully explain all conditions concerning the injury and/or OD. The United States Department of Labor, OSHA, requires employers to maintain a record of occupational injuries in the employer’s office. Please copy the completed form for your records. Insurer/Adjuster (not submitting electronically) Please complete all gray shaded areas, and mail a completed copy immediately to the Montana Department of Labor and Industry at the address shown below. Boxes that have been BOLDED are mandatory in order to file this report. If you wish to file First Report information electronically, please contact the Employment Relations Division. Further Information Department of Labor & Industry Employment Relations Division Workers’ Compensation Claims Assistance Bureau PO Box 8011 Helena MT 59604-8011 (406) 444-6543 http://erd.dli.mt.gov The United States Department of Labor, OSHA, requires employers to maintain a record of occupational injuries in the employer’s office. American LegalNet, Inc. www.USCourtForms.com First Report OSHA Log Case # Adjuster Date Stamp of Injury or Occupational Disease Montana Department of Labor and Industry PO Box 8011 Helena, MT 59604-8011 Worker LAST NAME FIRST NAME M.I. HOME ADDRESS DATE OF BIRTH SOCIAL SECURITY NUMBER CITY PHONE NUMBER EDUCATION GENDER MALE UNKNOWN LESS THAN HIGH SCHOOL GED OR HIGH SCHOOL DIPLOMA BEYOND HIGH SCHOOL STATE MARITAL STATUS MARRIED NOT MARRIED FEMALE POSTAL CODE NUMBER OF DEPENDANTS SEPARATED UNKNOWN Wages DATE HIRED GROSS EARNINGS FOR FOUR PAY PERIODS PRECEDING THE INJURY / DATE/AMOUNT / DATE/AMOUNT DATE/AMOUNT NUMBER OF DAYS WORKED PER WEEK EMPLOYMENT STATUS WAGE FULL TIME PART TIME SEASONAL VOLUNTEER IN ADDITION TO GROSS EARNINGS CITED ABOVE WORKER RECEIVED ESTIMATED VALUE IF ANY ROOM & BOARD OVERTIME BONUS COMMISSIONS OTHER OFF WORK MORE THAN 4 WORK DAYS YES NO NOT SURE WORKED NEXT SCHEDULED SHIFT YES NO DATE LAST WORKED / DATE/AMOUNT / WEEK MONTH OTHER BI-WEEKLY YEAR TIME EMPLOYEE BEGAN WORK HOUR DAY DATE OF RETURN TO WORK FULL WAGES PAID FOR DATE OF INJURY YES NO SALARY CONTINUED YES NO Accident Description JOB TITLE DESCRIPTION OF ACCIDENT CAUSE OF INJURY CAUSE CODE PART OF BODY PART CODE DATE DISABILITY BEGAN DATE OF DEATH ACCIDENT ON EMPLOYER’S PREMISES YES NO ACCIDENT ADDRESS OR LOCATION STATE CITY DATE EMPLOYER NOTIFIED NATURE OF INJURY NAMES OF WITNESSES 1) NATURE CODE DATE OF INJURY TIME OF INJURY 2) 3) SAFETY EQUIPMENT PROVIDED YES NO SAFETY EQUIPMENT USED YES NO POSTAL CODE ACCIDENT REPORTED TO Medical ATTENDING PHYSICIAN’S NAME ADDRESS STATE POSTAL CODE PHONE NUMBER HOSPITAL NAME ADDRESS STATE POSTAL CODE PHONE NUMBER TYPE OF INITIAL MEDICAL TREATMENT RECEIVED NO TREATMENT EMERGENCY ROOM TREATMENT ON-SITE BY EMPLOYER OR MEDICAL STAFF CLINIC/DR. OFFICE HOSPITAL Signature “This is my claim for workers’ compensation benefits due to the on-the-job injury, occupational disease or death of the above named worker. I understand that signing this claim for compensation authorizes the release to the workers’ compensation insurer or its agent, rehabilitation records, Social Security records and health care information (medical records, pursuant to HIPAA, Public Law 104-191, 42 USC section 1301, et. seq., and section 39-71-604, MCA) that are directly relevant to the claimed injury, disease or death. I also understand that if I obtain or exert unauthorized control over workers’ compensation benefits to which I am not entitled, I may be prosecuted for theft.” Signature of Injured Worker or Beneficiary Date Employer EMPLOYER NAME MAILING ADDRESS DOING BUSINESS AS CITY FEDERAL EMPLOYER IDENTIFICATION NUMBER (TAX ID) STATE POSTAL CODE NATURE OF BUSINESS SIC/NAICS CODE LOCATION OF OPERATION, IF DIFFERENT FROM MAILING ADDRESS EMPLOYER IS A SOLE PROPRIETORSHIP PARTNERSHIP CORPORATION LIMITED LIABILITY COMPANY SELF-INSURED? YES NO INJURED WORKER IS A SOLE PROPRIETORSHIP PARTNERSHIP CORPORATION LIMITED LIABILITY COMPANY A MEMBER OF THE EMPLOYER’S (SOLE PROPRIETOR OR PARTNER) FAMILY LIVING IN THE EMPLOYER’S HOUSEHOLD DO YOU HAVE ANY REASON TO QUESTION THIS ACCIDENT THIS ACCIDENT? IF YES, PLEASE EXPLAIN FULLY. USE SEPARATE SHEET IF YOU NEED ADDITIONAL SPACE Prepared By PHONE NUMBER YES WAS WORKER INJURED WHILE IN YOUR EMPLOY NO YES Official Title Phone Number NO Date PAYROLL CLASSIFICATION CODE UNDER WHICH YOU REPORT EMPLOYEE’S WAGES AUTHORIZED EMPLOYER’S SIGNATURE_______________________________________________ DATE__________________________ Insurer CLAIM ADMINISTRATOR CLAIM NUMBER THIRD PARTY ADMINISTRATOR’S NAME DATE REPORTED TO CLAIM ADMINISTRATOR THE ABOVE INFORMATION IS CORRECT WITH THE FOLLOWING EXCEPTIONS (ATTACH EXTRA SHEETS IF BOX AT RIGHT IS CHECKED) CLAIM ADMINISTRATOR ADDRESS INSURER FEIN INSURER NAME THIRD PARTY ADMINISTRATOR FEIN POLICY NUMBER POLICY EFFECTIVE DATE POLICY EXPIRATION DATE ERD – 991 (Rev. 01/2006 DE/LH) American LegalNet, Inc. www.USCourtForms.com