EMPLOYER’S REPORT INDUSTRIAL COMMISSION OF ARIZONA FOR CARRIER USE ONLY
OF INDUSTRIAL INJURY P.O. BOX 19070
PHOENIX, ARIZONA 85005-9070
COMPLETE AND MAIL THIS REPORT WITHIN 10 FOR OSHA PURPOSES ONLY
DAYS FROM NOTICE OF ACCIDENT. FATALITIES
MUST BE REPORTED WITHIN 24 HOURS. MAIL TO: (CARRIER NAME & ADDRESS)
OSHA Case #:
Employer must, on this form, notify his insurance carrier of every CompWest Insurance Company RECORDABLE INJURY
injury or disease suffered by an employee, fatal or otherwise, PO Box 12859, Newport Beach, CA 92658
which is claimed to arise our of or in the course of employment. or Fax to (866) 506-5800 ON-RECORDABLE INJURY
ARIZONA REVISED STATUTES 23-908 & 23-1061
EMPLOYEE
1. LAST NAME FIRST M.I.
2. SOCIAL SECURITY NUMBER ∗
3. BIRTH DATE
4. HOME ADDRESS (NUMBER & STREET) CITY STATE ZIP CODE 5. TELEPHONE
6.
SEX
o
MALE
o
FEMALE
7. MARITAL STATUS:
o
SINGLE
o
MARRIED
o
DIVORCED
o
WIDOWED
EMPLOYER
8. EMPLOYER’S NAME 9. POLICY NUMBER 10. NATURE OF BUSINESS (MANUFACTURING, ETC.)
11. OFFICE ADDRESS (NUMBER & STREET) CITY STATE ZIP CODE 12. TELEPHONE
ACCIDENT
13. DATE OF INJURY OR ILLNESS 14. TIME OF EVENT 15. TIME EMPLOYEE BEGAN WORK 16. DATE EMPLOYER NOTIFIED OF INJURY
A.M.
P.M.
A.M.
P.M.
17. LAST DAY OF WORK AFTER INJURY 18. DATE OF RETURN TO WORK 19. EMPLOYEE’S OCCUPATION (JOB TITLE) WHEN INJURED
20. CLASS CODE ON PAYROLL REPORT 21. EMPLOYEE’S ASSIGNED DEPARTMENT 22. DEPARTMENT NUMBER 23. DID INJURY OCCUR ON EMPLOYER PREMISES?
24. ADDRESS OR LOCATION OF ACCIDENT CITY COUNTY STATE ZIP CODE
25. WHAT WAS THE INJURY OR ILLNESS? Tell us the part of the body that was affected and how it was affected; be more specific than “hurt,” “pain,” or sore.” Examples: “strained back”; “chemical burn, hand”; “carpal tunnel syndrome.”
26. PART OF BODY INJURED 27. FATAL
o
YES
o
NO
28. IF THE EMPLOYEE DIED, WHEN DID THE DEATH OCCUR? DATE OF DEATH
29. WAS EMPLOYEE TREATED IN AN EMPERGENCY
ROOM?
NAME OF PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL ADDRESS (STREET, CITY, STATE & ZIP CODE)
30. WAS EMPLOYEE HOSPITALIZED OVERNIGHT AS
AN IN-PATIENT?
IF HOSPITALIZED, HOSPITAL NAME ADDRESS (STREET, CITY, STATE & ZIP CODE)
31. IF VALIDITY OF CLAIM IS DOUBTED, STATE REASON
CAUSE OF
ACCIDENT
32. WHAT HAPPENED? Tell us how the injury occurred. Examples: “When ladder slipped on wet floor, worker fell 20 feet”; “Worker was sprayed with chlorine when gasket broke during replacement”; “Worker
developed soreness in wrist over time.”
33. WHAT OBJECT OR SUBSTANCE DIRECTLY HARMED THE EMPLOYEE? Examples: “concrete floor”; “chlorine”; “radial arm saw.” If this question does not apply to the incident, leave it blank.
34. WHAT WAS EMPLOYEE DOING JUST BEFORE THE INCIDENT OCCURRED? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. Examples: “climbing a ladder while carrying
roofing materials”; “spraying chlorine from hand sprayer”; “daily computer key-entry.”
35. IF ANOTHER PERSON NOT IN COMPANY EMPLOY CAUSED ACCIDENT, GIVE NAME AND ADDRESS
EMPLOYEE’S
36. WAS WORKER IN YOUR EMPLOY
37. HOURS PER DAY EMPLOYEE WORKED 38. WAS EMPLOYEE ON OVERTIME
39. NUMBER OF DAYS PER WEEK
WAGE DATA
o
YES
o
NO
FROM A.M. P.M. THRU A.M. P.M.
o
YES
o
NO
EMPLOYEE
COMPANY
IMPORTANT
IF WORK LOSS IS EXPECTED TO EXCEED SEVEN
CALENDAR DAYS, COMPLETE ITEMS 40 THRU 47
40. DATE OF LAST HIRE 41. WAS WORKER PAID FOR DAY OF INJURY?
o YES o NO IF YES, $
42. WAS EMPLOYEE HIRED FOR PERMANENT
EMPLOYMENT?
43. NUMBER OF MONTHS EMPLOYMENT
AVAILABLE DURING THE YEAR
44. GIVE EMPLOYEE’S WAGE STATUS AS APPLICABLE
HOUR DAY WEEK MONTH
45. IS EMPLOYEE FURNISHED VALUE
46. ACTUAL GROSS EARNINGS OF EMPLOYEE FOR THE 30 CALENDAR DAYS PRECEEDING INJURY
(EXAMPLE: IF INJURED APRIL 8, GIVE EARNINGS FROM MARCH 9 THRU APRIL 7)
47. DOES EMPLOYEE CLAIM DEPENDENTS? o YES o NO
IMPORTANT
IF EMPLOYEE IS PAID OTHER THAN FIXED WEEKLY
OR MONTHLY SALARY, COMPLETE ITEMS 48 THRU 55
48. IF EMPLOYEE EARNS EXTRA PAY FOR OVERTIME, WHAT IS BASIS OF
PAYMENT?
PER HOUR
49. NUMBER OF HOURS OVERTIME CONSIDERED
NORMAL PER WEEK
50. GROSS WAGES OF EMPLOYEE DURING 12 MONTHS PRECEEDING INJURY 51. IF EMPLOYEE WORKED LESS THAN 12 MONTHS, SHOW GROSS WAGES FROM DATE OF HIRE THROUGH
FROM
THRU
$
FROM
THRU
$
52. DATE OF LAST WAGE INCREASE IF
WITHIN 12 MONTHS PRIOR TO INJURY
53. WAGE BEFORE INCREASE
$
54. WAGE AFTER INCREASE
$
55. GROSS EARNINGS FROM DATE OF INCREASE THRU DAY PRIOR TO INJURY
$
AUTHORIZED
SIGNATURE
DATE AUTHORIZED SIGNATURE
TITLE
NOTE TO EMPLOYER: 1. Mail one copy to the Industrial Commission within 10 days.
2. Mail one copy to your insurance carrier within 10 days.
3. Keep one copy, for not less than five (5) years, as your supplementary record of injuries required by the
Federal Occupational Safety and Health Act of 1970.
∗ The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of
1974, because the Commission’s forms, prescribed under the Commission’s Rules in existence prior to January 1, 1975, required disclosure of the social security number. The number is used as a means of identifying all the various records
in the Claims Division or Special Fund pertaining to an individual. The use of social security numbers is made necessary because of the large number of persons who have similar names and birth dates, and whose identities can only be
distinguished by the social security number.
Form ICA 04-0101 (Rev. 7/01)
THIS FORM APPROVED BY THE INDUSTRIAL COMMISSION OF ARIZONA FOR CARRIER USE
Please Fax Form to 866-835-5331 or e-mail to claimsfaxwest@compwestinsurance.com
Please Fax Form to 866-835-5331 or e-mail to claimsfaxwest@compwestinsurance.com
