First Report of Injury Form

First Report of Injury Form

To report a claim: Call 720-927-8683 or 833-927-1677 or, go to servicehub.pinnacol.com
Early reporting can save you money. Report all injuries immediately!
The information below allows Pinnacol Assurance’s customer service representatives to quickly and accurately process your claim. Use the completed form as a guide when reporting by phone or online to save you time. Don’t wait to report if you don’t have all the answers.
Form Prepared By:
Name
Prepares Title:
E-mail Address:
Fax:
Please enter a valid phone number.
Phone:
Please enter a valid phone number.
Date Completed:

MonthDayYear
Date
Injured Worker Information
Injured Worker's Social Security Number:
Date of Injury:

MonthDayYear
Date
Injured Employee Name:

First NameLast Name
Home Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employee Phone Number:
Please enter a valid phone number.
Date of Birth:

MonthDayYear
Date
Sex:

MaleFemale
Marital Status:
Language

EnglishSpanishOther
E-mail:
example@example.com
Occupation:
Date Hired:

MonthDayYear
Date
Employee Status:

Full-TimePart-TimeSeasonalVolunteerIndependent Contractor
Days Worked Per Week:
Hours Worked per Week:
Pay Rate
Salary Type

HourlyWeeklyMonthlyAnnualyOther
Accident / Injury Information
Fatal Injury:

YesNo
If Fatal Injury: Date of Death

MonthDayYear
Date
Time of Injury:

Hour Minutes

AM/PM Option
Time work began:

Hour Minutes

AM/PM Option
Last Day Worked:

MonthDayYear
Date
Full Pay on Date of Injury:

YesNo
Accident Occured on Employers Premises:

YesNo
Accident Location:
Name of Employer Representative Notified:
Date Notified:

MonthDayYear
Date
Witnessess:
Name(s) and Phone Nnumber(s)
How Did the Injury Occur:
Specific Activity the Employee was Engaged In:
What Equipment Was Being Used:
Body Part(s) Injured:
RightLeftNot Applicable
Type of Injury Sustained:
Safety Equipment ProvidedSafety Equipment UsedPossible Drug/Alcohol InvolvedEmployer Questioning Liability
Return to Work Information
Has the injured employee returned to work?

YesNo
Date Returned to Work:

MonthDayYear
Date
Estimated Return to Work Date:

MonthDayYear
Date
Is this a lost time claim?

YesNo
(it is lost time if there is a loss of more than three scheduled work days due to the injury)
Medical Provider Information
Where was the Employee Treated?

No Medical TreatmentTreated by Employer911 CalledWalk-In ClinicEmergency ClinicHospitalized>24 hrs/OvernightPossible Surgery
Medical Provider Name:
Medical Provider Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical Provider Phone Number:
Please enter a valid phone number.
PINNACOL ASSURANCE FIRST REPORT OF INJURY FORM INSTRUCTIONS
1. Report all work-related injuries within 24 hours! Quick reporting can significantly reduce the total cost of the claim. Our goal is to get your employee back to work as quickly as possible and reporting within 24 hours streamlines that process. Report the injury to Pinnacol Assurance even if you question whether the injury is truly job related. Provide information as to why you question the validity of the claim.

2. This form is a guide for reporting injuries by phone, or fax using the numbers on the front of this form. Online reporting is fastest. To report online, go to www.pinnacol.com, select “Quicklinks,” then “Report an Injury.” The employer or authorized representative should report the injury to Pinnacol Assurance; please do not have the injured worker complete this form.

3. Within 7 days after notification of an injury, the employer is required to provide the injured worker with a list of four medical providers who have been designated by the employer to provide medical treatment for the injured employee. The injured worker
must choose one of the designated providers from this list. Designating providers from Pinnacol's SelectNet list helps ensure your employee is seen by an occupational medical provider knowledgeable about the workers' compensation system and return to work issues. If you do not have four designated providers, call Pinnacol for assistance.

4. When reporting a claim by phone or the Internet, a copy of the completed form will be mailed to you for your records. Please review the copy to ensure all information is correct. If changes are needed, please contact Pinnacol’s claim representative assigned to the claim.

5. If the injured worker owes court ordered child support, compensation benefits may be attached and payment of the child support obligation may be withheld and forwarded to the obligee. (C.R.S. 8-42-124 & 26-16-122(4))

Please answer as many questions as possible for Pinnacol to begin processing the claim. Don't wait to report if you don't have all the answers, however all questions on this form will need to be completed in order to meet the requirements of the Colorado Workers' Compensation Act. Especially critical is the information regarding Date of Injury, if the injured worker will miss more than three scheduled days from work, and when you expect the injured worker to return to work.

Definitions:

Date of Injury: The date the accident occurred, or in the case of an occupational disease, the date of the first and last exposure.
Lost-Time Claim: The loss of more than three scheduled workdays due to the injury.
Wages and Time Worked: Provide either the weekly pay rate and hours OR the hourly pay rate and hours worked. Wages may also include: overtime wages, tips, commissions, room & board, housing, lodging and cost of health insurance. If you are unsure how to answer, call the customer service phone number on the front of this form.

Accident Location: Provide the address if the accident occurred on the employer’s premises or if it occurred outside the employer’s premises at an identifiable location. If it occurred at a place that cannot be identified by a
number or street, such as a public highway, provide references locating the place accurately as possible.

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or injured worker for the purpose of defrauding or attempting to defraud the policyholder or injured worker with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
OSHA FORM 301 QUESTIONS “If you had 10 or fewer employees during all of the last calendar year or your business is classified in a lowhazard industry specified by OSHA, you do not have to keep injury and illness records unless the Bureau of Labor Statistics or OSHA informs you in writing that you must do so.”

For this Pinnacol Assurance First Report of Injury to be considered equivalent to OSHA Form 301 (Injury and Illness Incident Report) the following questions must be completed along with the information on the front of this form. If you have questions regarding the OSHA recordkeeping standard contact your Pinnacol Assurance Safety Consultant.
Case Number From OSHA 300 Log
Was the Employee Hospitalized Overnight as an In-Patient?

YesNo
What was the Employee doing just Before the Incident Occurred?
Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. Examples: “climbing a ladder while carrying roofing materials,” “spraying chlorine from hand sprayer,” “daily computer key-entry.”
What was the Injury or Illness?
Tell us the part of the body that was affected and how it was affected; be more specific than “hurt,” “pain,” or“sore.” Examples: “strained back,” “chemical burns to hand,” “carpal tunnel syndrome.”
What Object or Substance Directly Harmed the Employee?
Examples: “concrete floor,” “chlorine,” “radial arm saw.” If this question does notapply to the incident, leave blank.
What was the Name of the Physician/Health Care Professional Who Provided Medical Treatment to the Employee?
Should be Empty:

First Report of Injury Form

Injured Worker Information

Accident / Injury Information

Return to Work Information

Medical Provider Information

PINNACOL ASSURANCE FIRST REPORT OF INJURY FORM INSTRUCTIONS