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WORKERS COMPENSATION FIRST REPORT OF INJURY OR ILLNESS
Employer (Name & Address incl. zip) Carrier/Administrator Claim Number Jurisdiction General Jurisdiction Claim No. Report Purpose Code
Insured Report No. Employer's Location Address (if different) Location No.
Sic Code
Employer FEIN
Phone No.
Carrier (Name, Address & Phone Number) Carrier/Claims Admin
Policy Period To Check if self insured
Claims Admin (Name, Address & Phone Number)
Carrier FEIN Agent Name & Code Number Legal Name (Last, First, Middle) Address (Incl. Zip)
Policy Number or Self-Insured Number
Administrator FEIN
Birth Date Sex Male
Social Security Number Marital Status Unmarried/ Single/Div. Married Separated Unknown
Date Hired Occupation/Job Title
State of Hire
Employee
Phone
Female Unknown No. of Dependents
Employment Status NCCI Class Code
Wage Rate
$
Time Employee Began Work AM PM
Day Week Date of Injury or Illness
Month Other Time Occurred
# Days Worked/WK # Hrs Worked per Day
Full Pay for Date of Injury? Did Salary Continue? Date Employer Notified
Yes Yes Date Disability Began
No No
AM PM
Last Work Date
Employer Contact Name/Phone Number Did Injury/Illness Exposure Occur on Employer's Premises? Occurrence Yes No
Type of Illness/Injury Type of Illness/Injury Code
Part of Body Affected Part of Body Affected Code
Department or location where accident or illness exposure occurred
All Equipment, Materials, or Chemicals Employee Using upon Occurrence
Specific Activity Employee Engaged in at Time of Occurrence
Work Process the Employee Was Engaged in at Time of Occurrence Cause of Injury Code Yes Yes Initial Treatment No Medical Treatment Minor: By Employer Minor Clinic/Hosp Emergency Care Hospitalized 24 hr. Anticipated Major Med/Lost Time N o N o
How injury or illness/abnormal health condition occurred. Describe the sequence of events and include any objects or substances that directly injured the employee or made the employee ill. Date Returned to Work If Fatal, Date of Death Were Safeguards or Safety Equipment Provided? Were they used? Physician/Health Care Provider (Name & Address) Treatment Hospital (Name & Address) 0 1 2 3 4 5
Other
Signature of Injured Employee, or Signature on File, Date Date Administrator Notified Date Prepared
Witness to Accident (Name & Phone Number)
Preparer's Name & Title
Preparer's Phone Number
Filing this report is not an admission of liability. This report shall not be evidence of any fact stated herein in any proceeding in respect of the injury, illness or death on account of which this report is made. Idaho Industrial Commission, P.O. Box 83720, Boise, ID 83720-0041 IC Form IA-1 (2/98)