TR-0169 (Rev. 6/12) RDA-413
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SECTION 1. MEMBER INFORMATION (continues)
When Was Employer First Notifi ed?
Name of Person Notifi ed
Notifi ed Person’s Position
Immediate Supervisor of Injured Person
Name the Body Part that Was Injured
Give Nature of Injury
Probable Length of Disability
Name of Physician Who Treated Injury
Physician Address
City State Zip Code Phone Number
Applicant’s Signature Date
SECTION 2. EMPLOYER INFORMATION
Name of Department, County, City or Institution
Position Held By Employee When Injured
Was Employee Engaged in this Occupation When Injured?
Yes No
If Not, Why?
Cause of Injury
Willful Misconduct Intoxication
Intentional Self-Infl iction Failure or Refusal to Use Safety Equipment
When Was Employer First Notifi ed?
Name Injured Body Part
Monthly Salary on Date of Injury $
Basis for Payment
Hourly Weekly Monthly Yearly
Will Employee Be on Leave Without Pay During Disability?
Yes No
Give Any Relative Knowledge of Injury
Supervisor’s Signature Date
