Employers First Report Of Occupational Injury Or Disease Form. This is a New Hampshire form and can be use in General Workers Comp.
Tags: Employers First Report Of Occupational Injury Or Disease, 8 WC, New Hampshire Workers Comp, General
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. EMPLOYER’S FIRST REPORT OF : Index No. NH DOL USE ONLY OCCUPATIONAL INJURY OR DISEASE (Form 8WC) Return to: The State of New Hampshire, Department of Labor : P.O. Box 2077, Concord, NH 03302-2077 (603) 271-3176 FAX: (603) 271-6149 : Calendar No. JUDICIAL SUBPOENA IMPORTANT; Every employer shall file this report as soon as possible after knowledge of any occupational injury or disease to an employee, but no later than five Plaintiff(s) days thereafter. Notice of disability of four or more days shall be filed no later than seven days after date of injury on Supplemental Report Form No. 13WCA. Failure to comply with any or all of the above carries a civil penalty of up to $2,500.00. RSA 281A:53. : -against- PLEASE TYPE OR PRINT. 1. Name of injured: First Middle Initial ILLEGIBLE OR INCOMPLETE FORMS WILL BE RETURNED. Last : 2. DOB: 3. Age: 4. Male : 6. Address: No. & St. City/Town 7. State: Defendant(s) : ...................................................... 10. Is there on file a N.H. Youth Employment Certificate?: EMPLOYEE INFORMATION 15. No. days worked PEOPLE THE per week: 11. Occupation when injured: TO 20. Date disability began: 21. Was injured paid in full for this day? Female 8. Zip Code: 12. Was this his/her regular occupation? If not, state regular occupation: 16. Average Weekly Earnings: 17. Was injured OF THE STATE OF NEW YORK hired in N.H.? ____ 5. SS No.: ____ 9. Tel. No.: 13. Wages per hr.: 14. No. hrs. worked per day: 19. Date & Time of Injury: 23. Name of Person notified: 22. Date supervisor/employer was first notified: 18. Date employment began: 24. Location/Jobsite where accident occured: 25. Describe fully how accident occurred and describe what employee was doing when injured: GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before 27. Part(s) of body injured: 28. Estimated length of disability: , the Honorable at the Court located at County of in room to work? , on 30. If so, what date? of the day , 20 31. , At what occupation or job? in the at o'clock noon, Returned at: Full Duty: ___________ Has injured returned 32. and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 26. Name of witness(es): 29. Alternative/Light Duty: ____________ 33. Equipment causing injury: 34. Were safeguards in place? 35. Was accident caused by injured’s failure to use safeguards or follow regulations? Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to No the party on whose behalfmedical treatment: ____ was issuedbyfor a maximum ____ Emergency care:and all Hospitalized: ____ this subpoena Care provide Employer only (on-site): penalty of $50 ____ damages sustained as a result of your failure to (Office Visit): ____ (Other-explain): _______________________________________________________________________________________________________ comply. Other: (Outpatient): ____ (Clinic): ____ 36. Initial Treatment: (check those that apply) 37. Name of treating physician: EMPLOYER INFORMATION 39. Name of treating hospital: Witness, Honorable Court in and/or D/B/A or Leasing Company Name: day of County, Legal Business Name 38. Has injured died? If so, what date? , one of the Justices of the 40. , 20 Employers Federal ID: 42. Business Address of No. 39 above: 45. Telephone Number: 41. If leased or temporary worker, client’s business name: 43. City/State: 44. Zip: (Attorney must sign above and type name below) 46. Insurance Co. (not agent) or Self Insured Group: 47. Managed Care Program? Y or N. If yes, name Provider: Attorney(s) for 48. No. of Employees: Full-time: 51. Business SIC Code Part-time: 49. Is there a Written Safety Program in force? 52. Type or Nature of Business in N.H.: 54. Employer Signature: 50. Is there an active Safety Committee? 53. If report sent by Insurance Agency, state name: Office and P.O. Address 55. Printed/Typed Name and Official Title: 56. Employee Signature (whenever possible): Form 8WC (7-95) 57. White – Labor Department Telephone No.: Date Facsimile No.: of this report: E-Mail Address: Mobile Tel. No.: Canary – Insurance Claims Office Pink – Employer’s Copy American LegalNet, Inc. www.USCourtForms.com