West Virginia Workers’ Compensation Employers’ Report of Occupational Injury or Disease Form OIC-WC-2 PLEASE PRINT OR TYPE Section I Employer Information Insurer: Third-Party Administrator: Employer’s Name: Nature of Business: FEIN: Address: City: State: Zip: Section II Telephone: ( ) - Employee Information Name: (Last): (First): (M.I.): Occupation/Job Title: Address: Telephone: ( City: State: Date of Birth: / / 6. Sex: Injured Employee is (check all that apply): Owner/Partner M Full-Time Officer F Part-Time Retired – Date Retired: Section III - - Marital Status: Volunteer / - Social Security No.: Zip: ) Employee’s Occupation/Job Title: / Information Regarding Injury or Disease Date of Injury or Last Exposure: / / Date Employer Notified of Injury or Disease: / / Time: a.m. p.m. Witnesses to Injury: Supervisor to whom Injury or Disease Reported: If Injury was Fatal, Indicate Date of Death: Did Injury Occur on Employer’s Property? occurred: / Yes / No Address or location where injury What was the Employee Doing when Injury Occurred (loading truck, walking down stairs, etc.): How did the Injury or Disease Occur (be specific; include time that employee began work on the date of injury, any equipment, tools, substances or objects connected to the injury; attach additional sheet if necessary): Nature of Injury or Disease (cut, bruise, strain, etc.): Body Part(s) Injured: Are You Aware of, or Do You Suspect, a Prior Injury to this Body Part? Do You Have Reason to Question this Injury? Yes Location of Initial Treatment: No No (If “yes,” attach a specific explanation to this form). Emergency Room? Section IV Date Hired: Yes Yes No Hospitalized? Yes No Wage and Lost Time Information / / Last Day Worked After Occupational Injury or Disease: Is Light Duty Available? / Date of Return to Work: Number of Work Days Lost: Yes No Are Wages Being Paid to Injured Employee During Disability? Yes No Daily rate of pay on the date of injury: $ Wage on Date of Injury: $ / / / Hours Worked per Week: per hour day week month If Employee has Returned to Work, is it Alternative or Modified Work? hour day week If “yes,” indicate current wage: $ per Yes month No and best quarter wages of preceding four quarters $ I certify the statements and answers set forth in this section are true and correct to the best of my knowledge. I am aware the law, specifically West Virginia Code §61-3-24e, provides for severe penalties if I knowingly certify a false report or statement and/or withhold a material fact regarding any information requested. I acknowledge the provisions of the aforementioned code and the severe penalties for knowingly with fraudulent intent aiding or abetting anyone in securing or attempting to secure benefits to which he or she is not entitled. Print Name: Signature: Title: _____________________________________________ Date: _______/________/________ American LegalNet, Inc. www.FormsWorkFlow.com