Convenient Forms

Workers Compensation
First Report of Injury or Illness

Employer

Name:
Address:
 
City:
Zip:
Phone:

Employer's Location
(If different)

Address:
 
City:
Zip:

Employee/Wage

Name:
Address:
 
City:
Zip:
Phone:
DOB:
Male Female Unknown
Marital Status:
Unmarried
Single/Divorced
Separated
Unknown
Date Hired:
State of Hire:
Occupation/Job Title:
Rate:
Average Weekly Wages:
# Days Worked/Week:
Social Security #:
Full Pay for Day of Injury:Yes No
Did Salary Continue:Yes No

Occurrence/Treatment

Contact Name:
Phone Number:
Date of Injury/Illness:
Type of Injury/Illness:
Part of Body Affected:
Did Injury/Illness Exposure
Occur on Employer's Premises:
Yes No
Time of Occurrence:
AM: PM:
Last Work Date:
Date Employer Notified:
Date Disability Began:
Department or Location Where Accident or
Illness Exposure Occurred:
Specific Activity the Employee was Engaged
in When the Accident or Illness Exposure Occurred:
Date Return(ed) to work:
If Fatal, Give Date of Death:
Were Safeguards or Safety Equipment Provided:Yes No
Where They Used:Yes No

Physician/Health Care Provider

Name:
Address:
 
City:
Zip:

Hospital or Offsite Treatment

Name:
Address:
 
City:
Zip:

Initial Treatment

No Medical Treatment
Minor: By Employer
Minor Clinic/Hosp
Emergency Care
Overnight Hospitalization
Future Major Medical/Lost Time Anticipated

Witnesses

Name:
Address:
 
City:
Zip:
Phone:
Date Prepared:
Preparer's Name & Title:
Spam Preventer:
   

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