First Report Of Injury

Fields marked with * are required

Employer's FEIN

Date of report

Case or File #

Is this a lost workday case?

Employer's name

Doing business as

Employer's mailing address

Nature of business or service

SIC code

Name of workers' compensation carrier/admin

Policy/Contract #

Self-insured?

Employee's full name

Social Security #

Birthdate

Employee's mailing address

Employee's email address

Male/Female

Married/Single

# Dependents

Employee's average weekly wage

Job title or occupation

Date hired

Time employee began work

Date and time of accident

Last day employee worked

If the employee died as a result of the accident, give the date of death

Was accident on employer's premises

Address of accident

What was the employee doing when the accident occurred?

How did the accident occur

What was the injury or illness? List the part of body affected and explain how it was affected

What object or substance, if any, directly harmed the employee

Name and address of physician/health care professional

If treatment was given away from the worksite, list the name and address of the place it was given

Was the employee treated in an emergency room

Was the employee hospitalized overnight as an inpatient

Report prepared by

Title and telephone #

Signature