WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESSWORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS
LWC-WC IA-1 IAIABC 2002
EMPLOYER (NAME & ADDRESS INCLUDING 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 # (IF AVAILABLE)
INDUSTRY CODE EMPLOYER FEIN PHONE #
CARRIER/CLAIMS ADMINISTRATOR
CARRIER (NAME, ADDRESS & PHONE #) POLICY PERIOD
TO
CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE #)
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 SEC. # (IF THERE IS ONE) DATE HIRED STATE OF HIRE
ADDRESS (INCLUDING ZIP) SEX MARITAL STATUS OCCUPATION/JOB TITLE
M MALE
U
UNMARRIED
SINGLE/DIVORCED
F FEMALE
M MARRIED
EMPLOYMENT STATUS
U UNKNOWN
S SEPARATED
PHONE # # OF DEPENDENTS
K UNKNOWN
NCCI CLASS CODE
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
CANNOT BE
DETERMINED
AM
LAST WORK DATE DATE EMPLOYER NOTIFIED DATE DISABILITY BEGAN
PM PM
CONTACT NAME/PHONE NUMBER PART OF BODY AFFECTED
DID INJURY/ILLNESS/EXPOSURE OCCUR
ON EMPLOYER’S PREMISES?
YES
TYPE OF INJURY/ILLNESS CODE PART OF BODY AFFECTED CODE
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 RETURNED 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 OR OFF-SITE TREATMENT (NAME & ADDRESS) INITIAL TREATMENT
NO MEDICAL TREATMENT
MINOR: BY EMPLOYER
MINOR: CLINIC/HOSPITAL
EMERGENCY CARE
HOSPITALIZED > 24 HOURS
FUTURE MAJOR MEDICAL/LOST TIME
ANTICIPATED
OTHER
WITNESS(ES) NAME(S) & PHONE #(S)
DATE ADMINISTRATOR NOTIFIED DATE PREPARED PREPARER’S NAME & TITLE PHONE NUMBER
TYPE OF INJURY/ILLNESS
