Iowa Workers’ Compensation – FIRST REPORT OF INJURY OR ILLNESS Jurisdiction Code______________ Jurisdiction Claim Number_______________
© IAIABC FORM 1.2 (12/98)
Claim Administrator Name: Claim Representative Business
Phone Number:
Insurer Name (if different than claim administrator):
Claim Administrator Claim Number:
Insurer FEIN:
CLAIM ADMIN
Mailing Address, City, State, & Postal Code:
Claim Administrator FEIN:
Claim Type Code:
Employer Name: Employer FEIN:
Insured Report Number:
Industry Code:
Employer Type Code:
__ Employer (E)
__ Lessor (L)
Physical Address, City, State, & Postal Code: Mailing Address, City, State, & Postal Code:
Insured Location Number: Employer UI Number:
EMPLOYER
Nature of Business: Employer Contact Name and Business Phone Number:
Coverage Effective Date:
POLICY
Insured Name (parent company if different than employer): Insured FEIN:
Insured Postal Code: Policy/Contract Number:
Coverage Expiration Date:
Self Insurance License/
Certificate Number:
Gender: Tax Filing Status (check one):
Employee Name (First, Middle, Last, & Suffix): Date of Birth:
__ Male (M) ____ Single (A) ____ Married/Filing Joint (C)
__ Female (F) ____ Single/Head of Household (B) ____ Married/Filing Separate(D) Date of Hire:
Educational Level (grade completed): _______ [GED = 12]
Employment Status (check one): Employee ID Number (check one):
Mailing Address, City, State, & Postal Code:
ID # ______________________ Phone Number (include area code):
Marital Status: (check one)
___ Unmarried (U)
___ Married (M)
___ Separated (S)
Occupation Description:
Employee’s Authorization to
Release the Following:
Manual Classification Code:
Medical Records __ yes
__
no
EMPLOYEE
Department Where Regularly Worked:
____ Piece Worker
____ Volunteer
____ Seasonal
____ Apprenticeship/Full-Time
____ Apprenticeship/Part-Time
____ Regular Employee/Full-Time
____ Part-Time
____ Other
____ Social Security Number
____ Employment VISA Number
____ Passport Number
____ Green Card
____ Employee ID Assigned by Jurisdiction
Social Security Number __ yes
__
no
Average Wage $ ___________ (check one):
Salary Continued In Lieu of Compensation: ___ yes ___ no Employee Number of Dependents: __________
___ hourly ___ daily ___ semi-monthly ___ monthly
___ bi-weekly ___ annual ___ weekly
Full Wages Paid for Date of Injury: ___ yes ___ no
Employee Number of Exemptions: ___________ (check
one)
___ Entitled
WAGE
Number of Days Regularly Worked Per Week: _______ Discontinued Fringe Benefits: $_____________
___ Withholding
Describe the nature of the injury. (ex. amputation, burn, cut, fracture):
_____________________ Date of Injury
_____________________ Date Employer Had Knowledge of the Injury
_____________________ Date Claim Administrator Had Knowledge of the Injury
_____________________ Initial Date Last Day Worked
_____________________ Initial Return to Work Date (if applicable)
_____________________ Employee Date of Death (if applicable)
_____________________ Time of Injury
_____________________ Time Employee Began Work
Pre-Existing Disability Code:
Part(s) of body directly affected by the injury or illness. (ex. hand, arm, circulatory system):
___ Yes
___ No
___ Unknown
Accident Premises Code:
___ Employer (E)
Describe the events that caused the injury. (ex. fell, operating machinery, chemical exposure):
___ Lessee (L)
___ Other (X)
Accident Site Organization Name:
Name the object or substance that directly injured the employee. (ex. knife, floor, acid, oil):
Accident Site Street, City, State, & Postal Code:
Accident Location Narrative (if no street address):
Specify activity the employee was engaged in when the event occurred. (ex. cutting metal plate for flooring) Indicate if activity was part of normal duties:
ACCIDENT/INJURY
Accident Site County/Parish: Witness Name & Business Phone Number:
Initial Treatment Code (check one):
___ no medical treatment (0)
___ minor/on-site treatment (1)
Initial Medical Provider Name:
___ clinic/hospital visit (2)
Managed Care Organization Name or ID Number:
___ emergency care (3)
___ hospitalization > 24 hours (4)
MEDICAL
___ future medical treatment/lost time anticipated (5)
Initial Medical Provider Physical Address, City, State, & Postal Code:
ICD Primary Diagnostic Code
(if known):
Preparer’s Name & Title: Preparer's Company Name: Phone Number: Date:
