WORKERS' COMPENSATION FIRST REPORT OF INJURY OR ILLNESS FORM
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Named Insured
Policy Number
Insured Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Department
Employee Occupation/Job Title:
Phone Number:
Please enter a valid phone number.
Employee Name:
First Name
Last Name
Employee Date of Birth:
-
Month
-
Day
Year
Date
Employee Phone:
Please enter a valid phone number.
Employee Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employee Social Security Number
Employee Married?
Yes
No
Employee Sex:
Male
Female
Employee Date of Hire:
-
Month
-
Day
Year
Date
Description of Incident:
RELEASE OF MEDICAL INFORMATION
I certify that the above information is true to the best of my knowledge and I authorize the release to my employer and workers' compensation company all records relevant to my disability and my claim for disability or workers' compensation benefits, including but not limited to medical diagnosis, prognosis, treatment, and periods of hospitalization. It is understood that the company will use the information to verify my disability and determine my eligibility of appropriate benefits. This authorization applies to physicians and other health care providers, hospitals, clinics, insurance companies, workers' compensation carriers, and organizations administering benefit programs. This authorization will remain in effect throughout my claim for workers' compensation benefits. A photocopy of this authorization will be as valid as the original.
Employee Signature:
Date:
-
Month
-
Day
Year
Date
INCIDENT DETAILS
Date of Incident:
-
Month
-
Day
Year
Date
Time of Incident
Date Incident was Reported:
-
Month
-
Day
Year
Date
Incident Location:
On Employer Premise?
Yes
No
Witness Name:
First Name
Last Name
Witness Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Witness Email:
example@example.com
Employee lost time due to injury:
Yes
No
First Aid Given?
Yes
No
Date Worker Left:
-
Month
-
Day
Year
Date
Time Worker Left:
Date Worker Returned:
-
Month
-
Day
Year
Date
Medical Facility:
Doctor:
Follow-Up Appointment Scheduled?
Yes
No
Time Off Approved by Physician?
Yes
No
If yes, how many days?
Treatment Given:
Prescription
Remove Foreign
Irrigation
Ace Bandage
Sutures
Tetanus Shot
Cast
Brace
None
Other
Part of Body Injured:
Head
Face
Left Eye
Right Eye
Nose
Neck
Other
Part of Body Injured:
Right
Left
Arm
Elbow
Forearm
Hand
Finger
Trunk
Shoulder
Chest
Back
Abdomen
Hip
Thigh
Knee
Leg
Ankle
Foot
Toe
Ribs
Skin
Nature of Injury (mark all that apply):
Abrasion
Burise-Crushed
Laceration
Amputation
Puncture
Fracture
Poisoning
Dermatitis
Chemical
Hearing
Sprain
Strain
Inhalation
Fatality
Heat/Cold
Foreign Object
Burn
Other
INVESTGATION SUPERVISOR
Date of Investigation:
-
Month
-
Day
Year
Date
Investigator Name:
First Name
Last Name
Employee's Supervisor:
First Name
Last Name
Supervisor's Phone:
Please enter a valid phone number.
Who was immediately in charge at time of injury:
If yes, explain:
Type a question
Cause of Injury (mark all that apply):
Bodily Motions
Bldg./Structure
Chemicals
Vehicles
Falling Objects
Hot/Cold
Conveyors
Electrical-HV
Electrical-LV
Flame/Smoke
Furniture
Hand Tool
Hoisting
Ladders
Machines
Notices
Particles
Slip/Trip/Fall
Flying Objects
Flash
Other
Cause of Incident (mark all that apply):
Equipment
Lack of Attention
Material Handling
Slippery Surface
Excessive Speed
Procedure Failure
Poor Housekeeping
Fatigue
Horseplay
ANALYSIS
Description of Incident:
Explain:
STEPS TAKEN TO PREVENT SIMILAR OCCURRENCE
Reinstruction of Employee
Reminder Instruction to All Employees
Personal Protective Equipment Required
Formal Disciplinary Action
Installation of Guard Device
Counseling of Employee
Form Completed by (your name):
First Name
Last Name
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Supervisor Signature:
Date:
-
Month
-
Day
Year
Date
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