TO AVOID PENALTY, THIS REPORT MUST BE Please EMPLOYERS REPORT OF INDUSTRIAL INJURY COMPLETED AND MAILED TO THE INSURER WITHIN OR OCCUPATIONAL DISEASE Type or Print 6 WORKING DAYS OF RECEIPT OF THE C-4 FORM Employers Name Nature of Business (mfg., etc.) FEIN OSHA Log # Office Mail Address Location . . . If different from mailing address Telephone City State Zip INSURER THIRD-PARTY ADMINISTRATOR EMPLOYER First Name M.I. Last Name Social Security Birthdate Age Primary Language Spoken Home Address (Number and Street) Sex Male Female Marital Status Single Married Divorced Widowed City State Zip Was the employee paid for the day of injury? How long has this person been employed by you in Nevada? (If applicable) Yes No In which state was employee hired? Employees occupation (job title) when hired or disabled Department in which regularly employed: EMPLOYEE Telephone Is the injured employee a corporate officer? . . . sole proprietor? . . . partner? Was employee in your employ when injured or disabled by occupational disease (O/D)? Yes No Yes No Yes No Yes No Date of Injury (if applicable) Time of injury (Hours; Minute AM/PM) (if applicable) Date employer notified of injury or O/D Supervisor to whom injury or O/D reported Address or location of accident (Also provide city, county, state) (if applicable) Accident on employers premises? (if applicable) Yes No What was this employee doing when the accident occurred (loading truck, walking down stairs, etc.)? (if applicable) DISEASE How did this injury or occupational disease occur? Include ti me employee began work. Be specific and answer in detail. Use additional sheet if necessary. ACCIDENT OR Witness Was there more than one Specify machine, tool, substance, or object most closely connected with the accident person injured in this (if applicable) accident? (if applicable) Part of body injured or affected If fatal, give date of death Witness Yes No Nature of Injury or Occupational Disease (scratch, cut, bruise, strain, etc.) Witness Did employee return to next scheduled shift after Will you have light duty work accident? (if applicable) available if necessary? Yes No Yes No If validity of claim is doubted, state reason Location of Initial Treatment Treating physician/chiropractor name Emergency Room Yes No Hospitalized Yes No How many days per week does Last day wages were earned INJURY OR DISEASE IMPORTANT employee work? From am pm To am pm Scheduled S M T W T F S Rotating Are you paying injured or disabled employees wages during disability? Yes No days off Date employee was hired Last day of work after injury or disability Date of return to work Number of work days lost Was the employee hired to If not, for how many hours a week Did the employee receive unemployment compensation any time during the last 12 work 40 hours per week? Yes No was the employee hired? months? Yes No Do not know For the purpose of calculation of the average monthly wage, indicate the employees gross earnings by pay period for 12 weeks prior to the date of injury or disability. If the injured employee is expected to be off work 5 days or more, attach wage verification form (D-8). Gross earnings will include overtime, bonuses, and other remuneration, but will not include reimbursement for expenses. If the employee was employed by you for less than 12 weeks, provide gross earnings from the date of hire to the date of injury or disability. In addition, if the employee was absent from work during the period for which payroll information is requested for any of the reasons listed below, please provide the date(s) absent and, from the fo llowing list, indicate, by numeral, the reason(s) for the absence(s). Gross earnings must not include wages earned after the date of injury or disability. 1. Certified illness or disability. 2. Institutionalized in hospital or other institution. 3. Enrolled as a full-time student, not employed on days when attending classes. 4. In military service other than that training duty conducted on weekends. 5. Absent because of an officially sanctioned IMPORTANT LOST TIME INFOstrike. 6. Approved FMLA absence. Pay period SUN TUE THUR SAT Emloyee WEEKLY MONTHLY OTHER On the date of injury or disability ends on: MON WED FRI is paid: BI-WKLY SEMI-MONTHLY the employees wage was: $ per Hr Day Wk Mo I affirm that the information provided above regarding the accident and injury or occupational disease is correct to Employers Signature and Title Date the best of my knowledge. I further affirm the wage information provided is true and correct as taken from the payroll records of the employee in question. I also understand that providing false information is a violation of Nevada law. Deemed Wage Account No. Class Code rd Claim is: Accepted Denied Deferred 3 Party Claims Examiners Signature Date Status Clerk Date Only Use resurn I Form C-3 (rev.01/03) ORIGINAL EMPLOYER PAGE 2 INSURER/TPA PAGE 3 EMPLOYEE