New Hampshire Employee Name (First & Last) Employee ID Employee Address Employer's First Report of Injury Submission Date: WEB-8WC � NHDOL# � Hired Date Hired in NH EMPLOYEE INFORMATION Date of Birth Telephone Age Gender Occupation when Injured Hrs per Day Days per Week Average Weekly Earnings Wages per Hour INJURY INFORMATION Injury Date / Time Disability Began Date Claim Type Accident Description Full Wages Paid on Injury Date Date Employer Notified of Injury Location/Jobsite & Business Name where accident occurred Body part Injured Nature of Injury Has injured returned to work? Initial Treatment Initial Treatment Comments Name of Treating Physician If so, what date? Cause of Injury Witness Name If so, at what occupation? Witness Phone If so, at what duty status? Name of Treating Hospital Has injured died? If so, what date EMPLOYER INFORMATION Employer Name Employer Contact Name Managed Care Provider Leased Employee? Client Company OCIP/Wrap-Up Policy? Name of policy holder Contact Phone Number Employer FEIN Employer Business Address Industry Code Insurance Carrier INSURER INFORMATION Insurer Type Policy Number Telephone Number Submitter Name SUBMITTER INFORMATION Title of Submitter Represents Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com