Fillable Employee Accident Injury Report 101 (City of Beverly MA)

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Employee Accident Injury Report 101 (City of Beverly MA)

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File type: PDF

U.S.A. forms for City of Beverly MA

BROWSE CITY OF BEVERLY MA (MA) FORMS

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The Commonwealth of Massachusetts
Department of Industrial Accidents – Department 101
600 Washington Street – 7th Floor, Boston, Massachusetts 02111
Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470
http://www.mass.gov/dia
EMPLOYER’S FIRST REPORT OF INJURY
OR FATALITY
THIS FORM MUST BE FILED BY THE EMPLOYER IN THE EVENT OF AN INJURY THAT RESULTS IN DEATH
OR FIVE OR MORE CALENDAR DAYS OF TOTAL OR PARTIAL INCAPACITY FROM EARNING WAGES.
INSTRUCTIONS AND CODES ON THE REVERSE SIDE - Please Print Legibly or Type - Unreadable forms will be returned.
DIA USE ONLY
FORM 101
Form 101 - Revised 8/2001 - Reproduce as needed.
THIS FORM DOES NOT CONSTITUTE AN EMPLOYEE’S CLAIM FOR BENEFITS UNDER WORKERS’ COMPENSATION.
1. Employee’s Name (Last, First, MI):
2. Home Telephone Number:
5. Home Address (No., Street, City, State & Zip Code):
8. Date of Hire (mm/dd/yyyy):
11. Employer’s Name:
12. Federal Tax I.D. Number:
13. Employer’s Address (No., Street, City, State & Zip Code):
16. Workers’ Compensation Insurance Carrier and Tel. No. (NOT LOCAL AGENT/ADMINISTRATOR):
14. Employer’s Telephone Number:
20. DATE OF INJURY (mm/dd/yyyy):
21. Was Employee Injured on Employer’s Premises? Yes No
23. FIRST day of Total or Partial Incapacity to Earn Wages
(mm/dd/yyyy):
27. Briefly Describe How Injury/Exposure Occurred and Body Part(s) involved:
28. Person to Whom Injury was Reported (list position):
E
M
P
L
O
Y
E
E
3. Social Security Number*:
4. Sex:
M F
6. Marital Status:
M S
7. No. of Dependents:
9. Date of Birth (mm/dd/yyyy): 10. Average Weekly Wage:
Estimated Actual$
E
M
P
L
O
Y
E
R
15. Industry Code (See Reverse Side):
17. W.C. Policy Number:
18. Self-Insured? Yes No
If Yes, Self-Insurer Number:
19. Business Type :
Service Wholesale Mfg.
Retail Other ________________________
I
N
J
U
R
Y
I
N
F
O
R
M
A
T
I
O
N
22. Location of Injury if not on Employer’s Premises:
25. If Employee has Died, Date of Death (mm/dd/yyyy):
24. FIFTH day of Total or Partial Incapacity to Earn Wages
(mm/dd/yyyy):
29. Date Reported (mm/dd/yyyy): 30. Date Reported as work related
(mm/dd/yyyy):
31. Injury Code(s)
a. to body part
b. to body part
c. to body part
Body Part Code(s)
a.
b.
c.
32. Witness(es) to Injury - Give Full Name(s), if none state as such:
33. Has Employee Returned to Work? Yes No 34. Date Employee Returned to Work(mm/dd/yyyy):
35. Employee’s Regular Occupation:
36. Has Employee Returned to Regular Occupation: Yes No
37. EMPLOYER’S Name (SEE INSTRUCTIONS ON REVERSE SIDE): 38. Title:
39. EMPLOYER’S Signature (SEE INSTRUCTIONS ON REVERSE SIDE): 40. Date Prepared (mm/dd/yyyy):
26. Source of Injury (Chemicals, Machinery, etc.):
*Disclosure of Social Security Number is Voluntary. It will aid in the processing of your report.
ACCIDENT REPORTING FORM: TO BE COMPLETED BY EMPLOYEE,
REVIEWED AND SIGNED BY SUPERVISOR FOR ACCURACY
1. EMPLOYEE Name (Last, First, MI)
4. Home Address (No & Street, City, State Zip Code) 5. Marital Status
Single
Married
6. Number of Dependents
7. Date of Hire (MM/DD/YY): 8. Date of Birth (MM/DD/YY):
9. Sex
Male
Female
10. Hourly Wage
$
11. Hours Worked Per Day
FT PT
12. Days Worked Per Week 13. Average 52-Week $_________________________
Estimated Actual
14. EMPLOYER Address (No & Street, City/State/Zip) 16. Department Employee Works:
20.. Source of Injury (e.g., Machine, Tool, Substance, etc.)
21. Address/Building/School Name where Injury Occurred 22. On Employer’s Premises: Yes No
Where? i.e. stairway, parking lot, classroom, curb, street
23. Hospital Name/Treating Doctor Name and Address 24. Regular Occupation 25. Regular Occupation when
Injured?
Yes
No
26. Name of Supervisor to Whom Was Injury Reported:
28. DESCRIBE IN DETAIL How Injury Occurred (I was walking down stairs and……)
29. Injured Body Part(s) Left Arm, Right Leg, Back and Hip 30. Nature of Injury(ies) (Burn, Fracture, Fall, Cut, Strain)
31. Witnesses to the Accident
SIGNATURES
3
4
.
S
UPERVISOR
’
S
Na
me
/
Title:
3
6
.
PREPARER
’
S
Name
/
Title
(
i
f
Employee is
u
nab
le to
c
o
mplet
e
and if so, provide reason)
37. Preparer’s Signature and Date
15. Employer Telephone
2. Phone Number 3. Social Security Number
18. Date of Injury MM/DD/YY):
27. Date Reported (MM/DD/YY):
19. Time of Injury
A.M. P.M.
32. EMPLOYEE’S Name/Title
_____________________________________________________________________
17. Employer Name/Insurance Carrier: Name and Address of Branch Responsible for This Case (Not Local Agent or Adjuster)
35. Supervisor’s Signature and Date (MM/DD/YY):
_____________________________________________
I have
reviewed this form for accuracy
33. Employee’s Signature and Date (MM/DD/YY):
_______________________________________________
City of Beverly, 191 Cabot Street, Beverly, MA 01915
City of Beverly c/o FutureComp, 12 Gill Street, Suite 5500, Woburn, MA 01801
I certify this is true and accurate
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Employee Accident Injury Report 101 (City of Beverly MA)

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Completed 20 July 2020

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