Fillable WORKERS COMPENSATION FIRST REPORT OF INJURY OR ILLNESS (National American Insurance Company)

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WORKERS COMPENSATION FIRST REPORT OF INJURY OR ILLNESS (National American Insurance Company)

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WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS
General
Employer (Name & Address incl. zip)
Carrier/Administrator Claim Number
Report Purpose Code
Jurisdiction
Jurisdiction Claim No.
Insured Report No.
Employer’s Location Address (if different)
NAICS Code
Employer FEIN
Carrier/Claims Admin
Carrier (Name, Address & Phone Number)
Policy Period
Claims Admin (Name, Address & Phone Number)
To
Check if
self
insured
Carrier FEIN
Policy Number or Self-Insured Number
Administrator FEIN
Agent Name & Code Number
Employee
Legal Name (Last, First, Middle)
Birth Date
Social Security Number
Date Hired
State of Hire
Address (Incl. Zip)
Sex
Marital Status
Occupation/Job Title
Male
Unmarried/
Single/Div.
Female
Married
Employment Status
Unknown
Separated
Phone
No. of Dependents
Unknown
NCCI Class Code
Wage Rate
$
Day
Month
# Days Worked/WK
Full Pay for Date of Injury?
Yes
No
Week
Other
# Hrs Worked per Day
Did Salary Continue?
Yes
No
Occurrence
Time Employee
Began Work
AM
Date of Injury
or Illness
Time
Occurred
AM
Last Work Date
Date Employer Notified
Date Disability
Began
PM
PM
Employer Contact Name/Phone Number
Type of Illness/Injury
Part of Body Affected
Did Injury/Illness Exposure Occur on Employer’s
Premises?
Yes
ype of Illness/Injury Code
Part of Body Affected Code
No
Department or location where accident or illness exposure occurred
All Equipment, Materials, or Chemicals Employee Using upon Occurrence
Specific Activity Employee Engaged in at Time of Occurrence
Work Process the Employee Was Engaged in at Time of Occurrence
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 Returned to Work
If Fatal, Date of Death
Were Safeguards or Safety Equipment Provided?
Yes
No
Were they used?
Yes
No
Treatment
Physician/Health Care Provider (Name & Address)
Hospital (Name & Address)
Initial Treatment
0
No Medical Treatment
1
Minor: By Employer
2
Minor Clinic/Hosp
3
Emergency Care
4
Hospitalized – 24 hr.
Other
Signature of Injured Employee, or Signature on File,
Date
Witness to Accident (Name & Phone Number)
5
Anticipated Major Med/Lost
Time
Date Administrator Notified
Date Prepared
Preparer’s Name & Title
Preparer’s Phone Number
Filing this report is not an admission of liability. This report shall not be evidence of any fact stated herein in any proceeding in respect of the injury,
illness or death on account of which this report is made. Idaho Industrial Commission, P.O. Box 83720, Boise, ID 83720-0041 IC Form IA-1
(08/2013)
Type of Illness/Injury Code
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WORKERS COMPENSATION FIRST REPORT OF INJURY OR ILLNESS (National American Insurance Company)

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Completed 29 July 2021

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