MWCC - WORKERS' COMPENSATION - FIRST REPORT OF INJURY OR ILLNESS
EMPLOYER (NAME & ADDRESS INCL ZIP) CARRIER/ADMINISTRATOR CLAIM NUMBER REPORT PURPOSE CODE JURISDICTION JURISDICTION CLAIM NUMBER
INSURED REPORT NUMBER
EMPLOYER'S LOCATION ADDRESS (IF DIFFERENT) SIC CODE EMPLOYER FEIN
LOCATION # PHONE #
CARRIER/CLAIMS ADMINISTRATOR
CARRIER (NAME, ADDRESS & PHONE NO) POLICY PERIOD TO
CHECK IF APPROPRIATE
CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO)
SELF INSURANCE CARRIER FEIN POLICY/SELF-INSURED NUMBER ADMINISTRATOR FEIN
AGENT NAME & CODE NUMBER
EMPLOYEE/WAGE
NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH SOCIAL SECURITY NUMBER DATE HIRED STATE OF HIRE
ADDRESS (INCL ZIP)
SEX MALE (M) FEMALE
MARITAL STATUS UNMARRIED/SINGLE/DIVORCED MARRIED
OCCUPATION/JOB TITLE
(U)
EMPLOYMENT STATUS
(F) UNKNOWN (U)
(M) (S)
PHONE
# OF DEPENDENTS
SEPARATED
NCCI CLASS CODE
UNKNOWN (K) RATE PER: DAY WEEK MONTH OTHER: #DAYS WORKED WEEK FULL PAY FOR DAY OF INJURY? DID SALARY CONTINUE? YES YES NO NO
OCCURRENCE/TREATMENT
TIME EMPLOYEE BEGAN WORK CONTACT NAME/PHONE NUMBER AM PM DATE OF INJURY/ILLNESS TIME OF OCCURRENCE AM LAST WORK DATE PM TYPE OF INJURY/ILLNESS PART OF BODY AFFECTED DATE EMPLOYER NOTIFIED DATE DISABILITY BEGAN
DID INJURY/ILLNESS EXPOSURE OCCUR ON EMPLOYER'S PREMISES? YES NO COUNTY WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED
TYPE OF INJURY/ILLNESS CODE
PART OF BODY AFFECTED CODE
ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED
SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED
WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED
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 CAUSE OF INJURY CODE
DATE RETURN(ED) TO WORK
IF FATAL, GIVE DATE OF DEATH
WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? WERE THEY USED? HOSPITAL (NAME & ADDRESS)
YES YES INITIAL TREATMENT NO MEDICAL TREATMENT (0) MINOR: BY EMPLOYER (1) MINOR CLINIC/HOSP (2) EMERGENCY CARE (3)
NO NO
PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS)
WITNESSES (NAME & PHONE #)
DATE ADMINISTRATOR NOTIFIED
DATE PREPARED
PREPARER'S NAME & TITLE
HOSPITALIZED > 24 HRS (4) FUTURE MAJOR MEDICAL/ LOST TIME ANTICIPATED (5) PHONE NUMBER
IAIABC IA-1 (8/01)
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