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) LOCATION #
SIC CODE EMPLOYER FEIN PHONE #
CARRIER/CLAIMS ADMINISTRATOR
CARRIER (NAME, ADDRESS & PHONE NO) POLICY PERIOD CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO)
TO
CHECK IF APPROPRIATE
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 MARITAL STATUS
OCCUPATION/JOB TITLE
MALE
(M) UNMARRIED/SINGLE/DIVORCED (U)
FEMALE (F) MARRIED (M)
EMPLOYMENT STATUS
UNKNOWN
(U)
SEPARATED (S)
PHONE # OF DEPENDENTS NCCI CLASS CODE
UNKNOWN
(K)
RATE
DAY MONTH
#DAYS WORKED WEEK
FULL PAY FOR DAY OF INJURY? YES NO
PER:
WEEK
OTHER: DID SALARY CONTINUE? YES NO
OCCURRENCE/TREATMENT
TIME EMPLOYEE
BEGAN WORK
AM
DATE OF INJURY/ILLNESS TIME OF
OCCURRENCE
AM
LAST WORK DATE DATE EMPLOYER NOTIFIED DATE DISABILITY BEGAN
PM PM
CONTACT NAME/PHONE NUMBER TYPE OF INJURY/ILLNESS PART OF BODY AFFECTED
DID INJURY/ILLNESS EXPOSURE OCCUR ON EMPLOYER’S PREMISES?
TYPE OF INJURY/ILLNESS CODE PART OF BODY AFFECTED CODE
YES NO
COUNTY WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED
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? YES NO
WERE THEY USED? YES NO
PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS) HOSPITAL (NAME & ADDRESS) INITIAL TREATMENT
NO MEDICAL TREATMENT (0)
MINOR: BY EMPLOYER (1)
MINOR CLINIC/HOSP (2)
EMERGENCY CARE (3)
WITNESSES (NAME & PHONE #) HOSPITALIZED > 24 HRS (4)
FUTURE MAJOR MEDICAL/
LOST TIME ANTICIPATED (5)
DATE ADMINISTRATOR NOTIFIED DATE PREPARED PREPARER’S NAME & TITLE PHONE NUMBER
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