Enter all dates in MM/DD/YY format.
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.
Transfer the case number from the OSHA 300 log after you record the case there.
The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer of the claimant.
Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administer- ing the claim.
Enter the name of your insurance agent and his/her code number if known. This information can be found on your insurance policy.
This is the primary occupation of the claimant at the time of the accident or exposure.
Indicate the employee's work status. The valid choices are: On Strike Disabled Retired
Full-Time Part-Time Not Employed
Unknown Apprenticeship Full-Time Apprenticeship Part-Time
Volunteer Seasonal Piece Worker
The first day on which the claimant originally lost time from work due to the occupation injury or disease or as otherwise deigned by statute.
Enter the name of the individual at the employer's premises to be contacted for additional information.
Briefly describe the nature of the injury or illness, (eg. Lacerations to the forearm
Indicate the part of body affected by the injury/illness, (eg. Right forearm, lower back
DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED:
(eg. 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.