WORKERS' COMPENSATION FIRST REPORT OF INJURY OR ILLNESS FORM
Insured Name:
*
First Name
Last Name
Policy Number:
*
Insured Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employee Occupation / Title:
Department:
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employee Name:
*
First Name
Last Name
Employee Date of Birth:
*
-
Month
-
Day
Year
Date
Employee Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employee Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employee Social Security Number:
*
Is 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
Hour Minutes
AM
PM
AM/PM Option
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 Woker Left:
Hour Minutes
AM
PM
AM/PM Option
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?
Part of Head Injured:
Face
Head
Nose
Neck
Other
Part of Body Injured:
Rows
Left
Right
Skin
Shoulder
Chest
Arm
Elbow
Forearm
Hand
Finger
Torso
Ribs
Hip
Thigh
Knee
Leg
Ankle
Foot
Toe
Nature of Injury
Abrasion
Amputation
Bruise-Crushed
Burn
Chemical
Dermatitis
Fatality
Foreign Object
Fracture
Hearing
Heat/Cold
Inhalation
Laceration
Poisoning
Puncture
Sprain
Strain
Other
Treatment Given:
Brace
Cast
Irrgation
None
Prescription
Remove Foreign
Sutures
Tetanus Shot
Other
Investigation 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.
Format: (000) 000-0000.
Who was immediately in charge at time of injury?
Cause of Injury (mark all that apply):
Bodily Motions
Bldg./Structure
Chemicals
Conveyors
Electrical-HV
Electrical-LV
Falling Objects
Flame/Smoke
Flash
Flying Objects
Furniture
Hand Tool
Heat/Cold
Hoisting
Ladders
Machines
Notices
Particles
Slip/Trip/Fall
Vehicles
Other
Cause of Incident (mark all that apply):
Equipment
Excessive Speed
Fatigue
Horseplay
Lack of Attention
Material Handling
Poor Housekeeping
Procedure Failure
Slippery Surface
Other
If Other, Describe:
Analysis
Description of Incident:
Explain:
Steps Taken To Prevent Similar Occurrence
Select All That Apply:
Counseling of Employee
Formal Disciplinary Action
Installation of Guard Device
Personal Protective Equipment Required
Reinstruction of Employee
Reminder Instructio
Other
If Other, What:
Report Completed by (your name):
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Supervisor Signature:
Date
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: