Fillable S.C. WORKERS COMPENSATION COMMISSION FIRST REPORT OF INJURY (National American Insurance Company)

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S.C. WORKERS COMPENSATION COMMISSION FIRST REPORT OF INJURY (National American Insurance Company)

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S.C. WORKERS’ COMPENSATION COMMISSION – FIRST REPORT OF INJURY OR ILLNESS
EMPLOYER (NAME & ADDRESS INCL ZIP)
CARRIER/ADMINISTRATOR CLAIM
NUMBER
OSHA LOG NUMBER
REPORT PURPOSE CODE
JURISDICTION
JURISDICTION CLAIM NUMBER
INSURED REPORT NUMBER
EMPLOYER’S LOCATION ADDRESS (IF DIFFERENT)
LOCATION #
INDUSTRY CODE
EMPLOYER FEIN
PHONE #
CARRIER/CLAIMS ADMINISTRATOR
CARRIER (NAME, ADDRESS, & PHONE #)
POLICY PERIOD
TO
CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO)
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
Male
Female
Unknown
MARITAL STATUS
Unmarried/Single/Divorced
Married
Separated
Unknown
OCCUPATION/JOB TITLE
EMPLOYMENT STATUS
NCCI CLASS CODE
PHONE
# OF DEPENDENTS
RATE
PER:
DAY MONTH DAYS WORKED/WEEK
FULL PAY FOR DAY OF INJURY? YES NO
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
( ) CANNOT BE DETERMINED
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
DEPARTMENT OR LOCATION 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 THE 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?
WERE THEY USED?
YES
YES
NO
NO
PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS)
HOSPITAL OR OFF SITE TREATMENT (NAME & ADDRESS)
INITIAL TREATMENT
0
NO MEDICAL TREATMENT
1
MINOR: BY EMPLOYER
2
MINOR CLINIC/HOSP
3
EMERGENCY CARE
4
HOSPITALIZED > 24 HOURS
5
FUTURE MAJOR MEDICAL/ LOST TIME
ANTICIPATED
OTHER
WITNESSES (NAME & PHONE #)
DATE ADMINISTRATOR NOTIFIED
DATE PREPARED
PREPARER’S NAME & TITLE
PHONE NUMBER
WCC FORM 12A
REV. DATE 04/06
SEE INSTRUCTIONS FOR IMPORTANT INFORMATION REPRINTED WITH PERMISSION OF IAIABC
South Carolina Workers’ Compensation Commission
1612 Marion St.
P.O. BOX 1715
Columbia, SC 29202-1715
803-737-5722
EMPLOYER’S INSTRUCTIONS
DO NOT ENTER DATA IN SHADED FIELDS
DATES:
Enter all dates in MM/DD/YYYY format.
INDUSTRY CODE:
This is the code which represents the nature of the employer’s business, which is contained in the Standard
Industrial Classification Manual or the North American Industry Classification System, published by the Federal
Office of Management and Budget.
CARRIER:
The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of
the employer of the claimant.
CLAIMS ADMINISTRATOR:
Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administering
the claim.
AGENT NAME & CODE NUMBER:
Enter the name of your insurance agent and his/her code number if known. This information can be found on
your insurance policy.
OCCUPATION/JOB TITLE:
This is the primary occupation of the claimant at the time of the accident or exposure.
EMPLOYMENT STATUS:
Indicate the employee’s work status. The valid choices are:
Full-Time On Strike Unknown Volunteer
Part-Time Disabled Apprenticeship Full-Time Seasonal
Not Employed Retired Apprenticeship Part-Time Piece Worker
DATE DISABILITY BEGAN:
The first day on which the claimant originally lost time from work due to the occupation injury or disease or as
otherwise designated by statute.
CONTACT NAME/PHONE NUMBER:
Enter the name of the individual at the employer’s premises to be contacted for additional information.
TYPE OF INJURY/ILLNESS:
Briefly describe the nature of the injury or illness, (e.g. Lacerations to the forearm).
PART OF BODY AFFECTED:
Indicate the part of body affected by the injury/illness, (e.g. Right forearm, lower back).
DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED:
(e.g. Maintenance Department or Client’s office at 452 Monroe St., Washington, DC 26210)
If the accident or illness exposure did not occur on the employer’s premises, enter address or location.
Be specific.
WCC FORM 12A REV. DATE 04/06
South Carolina Workers’ Compensation Commission
1612 Marion St.
P.O. BOX 1715
Columbia, SC 29202-1715
803-737-5722
EMPLOYER’S INSTRUCTIONS – cont’d
ALL EQUIPMENT, MATERIAL OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS
EXPOSURE OCCURRED:
(e.g. Acetylene cutting torch, metal plate)
List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or operating
when the injury or illness occurred. Be specific, for example: decorator’s scaffolding, electric sander, paintbrush,
and paint.
Enter “NA” for not applicable if no equipment, materials, or chemicals were being used. NOTE: The items listed
do not have to be directly involved in the employee’s injury or illness.
SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE
OCCURRED:
(e.g. Cutting metal plate for flooring)
Describe the specific activity the employee was engaged in when the accident or illness exposure occurred,
such as sanding ceiling woodwork in preparation for painting.
WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED:
Describe the work process the employee was engaged in when the accident or illness exposure occurred, such
as building maintenance. Enter “NA” for not applicable if employee was not engaged in a work process (e.g.
walking along a hallway).
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:
(Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against
the hot metal.)
Describe how the injury or illness/abnormal health condition occurred. Include the sequence of events and
name any objects or substance that directly injured the employee or made the employee ill. For example:
Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The
worker’s right wrist was broken in the fall.
DATE RETURN(ED) TO WORK:
Enter the date following to most recent disability period on which the employee returned to work.
WCC FORM 12A REV. DATE 04/06
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S.C. WORKERS COMPENSATION COMMISSION FIRST REPORT OF INJURY (National American Insurance Company)

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Completed 29 July 2021

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