BI-3 01/11 West Virginia Workers' Compensation Employer's Report of Occupational Injury or Disease 1. BrickStreet Insurance Policy Number: EMPLOYER INFORMATION For BrickStreet Use Only Claim Number: Team Assigned: 2. FEIN or SSN: 3. Nature of Business: 4. Employer's Name: 5. Address: City: 1. Name: Last 2. Address: City: 3. Date of Birth: 5. Injured Employee is: (check all that apply) Owner / Partner Officer 1. Date of Injury or Last Exposure: State: Zip: 4. Sex: M F Volunteer a.m. First State: Zip: MI 6. Telephone: 6. Date Hired: 7. Telephone: - EMPLOYEE INFORMATION 8. Social Security Number: 9. Marital Status: 10. Employee's Occupation / Job Title: Full-Time Part-Time Retired ­ Date Retired: Time: p.m. 5. Witnesses to Injury: INFORMATION ABOUT INJURY / DISEASE 2. Date Employer Notified of Injury or Disease: 3. Supervisor to Whom Injury or Disease Reported: 4. If Injury was Fatal, Indicate Date of Death: 6. Did Injury Occur on Employer's Property? Yes No Address or location where injury occurred: 7. What was the Employee Doing When Injury Occurred? (loading truck, walking down stairs, etc.) 8. How did the Injury or Disease Occur? (Be specific, include time that employee began work on date of injury, any equipment, tools substances or objects connected to the injury; attach additional sheet(s) if necessary) 9. Nature of Injury or Disease (cut, bruise, strain, etc.) 10. Body Part(s) Injured: 11. Are you Aware of, or Do You Suspect, a Prior Injury to this Body Part? Yes No 12. Do you Have Reason to Question this Injury? Yes No (If "yes," attach a specific explanation to this form.) 13. Location of Initial Treatment: Emergency Room? Yes No Hospitalized? 1. Last Day Worked After Occupational Injury or Disease: Yes No WAGE AND LOST TIME INFORMAITON 2. Number of Work Days Lost: 5. Is Light Duty Available? Yes No 3. Date of Return to Work: 6. Wage on Date of Injury: $ Per Hour 4. Hours Worked Per Week: Day Week Month Month 7. Are Wages Being Paid to Injured Employee Yes No During Disability? 9. Daily Rate of Pay on Date of Injury: $ 8. If Employee Has Returned to Work, is it Alternative or Modified Work? If "yes," indicate current wage: $ Per Hour Day and best quarter wages of preceding four quarters: $ Yes No Week 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: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332 American LegalNet, Inc. www.FormsWorkFlow.com General instructions for completing the BI-3, "West Virginia Workers' Compensation Employer's Report of Occupational Injury or Disease" Please Read Carefully To the Employer: W.V. Code 23-4-1b requires you to report the injury to your carrier within five days of receipt of notification from an employee's injury. This form should not be used to file occupational pneumoconiosis or hearing loss claims. To report a claim, please contact BrickStreet at 1-866-452-7425. If completing this form, make a copy for your records. Return completed form to: BrickStreet Mutual Insurance P. O. Box 3151 Charleston, WV 25332-3151 When completing this form, please attach additional pages if space is needed. Also attach any witness statements and reports you wish to submit. American LegalNet, Inc. www.FormsWorkFlow.com