First Report of Injury

CLAIMANT/EMPLOYEE:

Name:

Home Address:

City, St, Zip:

Phone #:

SS#:

D.O.B.

Sex:

Male Female

Job Title:

Related to Owner:

Yes No

Relationship:

Date Hired:

EMPLOYER INFORMATION:

Employer:

Mailing Address:

Location (if different)

Nature of Business:

Employer Phone #:

WC Policy #:

PAYROLL INFORMATION:

Average Weekly Wage:

Employees Job Was (check one):

Full Time Part Time Seasonal Volunteer Other

Work Week (days worked):

Was the employee paid for a full day on the day of the injury/illness?

Yes No

Did the employee receive lodging or tips in addition to pay?

Yes No

If yes, describe:

Last date worked:

Last date paid:

In Full?

Yes No

Did you continue to pay the employee after the injury/illness (e.g. sick leave, vacation, disability, regular salary)?

Yes No

If Yes, is reimbursement requested?

Yes No

ACCIDENT INFORMATION:

Date of Accident:

Time of day employee began to work on date of injury:

AM PM

Time of Accident:

AM PM

Has the employee given you notice of injury/illness?

Yes No

Date Notice Provided:

If Yes, Name & Title of person whom accident was reported:

Oral Written

His or Her phone#

Address where accident occurred: Assured address?

Yes No

If No, please give address where accident occurred:

Was this location where the employee normally worked?

Yes No

If No, Why was employee there?

Employee's Supervisor:

Did Supervisor see injury happen?

Yes No Unknown

Did anyone else see the injury happen?

Yes No Unknown

If yes, name of witness:

What was employee doing when injured?

What body part was affected?

Was an object (e.g. forklift, hammer, acid?) involved in injury/illness?

Yes No

If Yes, What was it?

Was the injury the result of the use or operation of a licensed motor vehicle?

Yes No

If Yes:

Employer's vehicle Other vehicle

License plate number (if known)

Auto Insurance information:

Did the injury/illness result in the employee's death?

Yes No

If Yes, what was the date of death?

Are you disputing the accident? If so, why?

If Non-Work Related or You Are Disputing this claim then NYS Disability Insurance Information Required:

NYS DB Company:

Address:

City, State, Zip:

Policy#:

MEDICAL TREATMENT INFORMATION:

Date of Employee's first medical treatment:

None received Unknown

Where did the employee receive first medical treatment for this injury/illness?

Onsite Doctor's office Emergency Room Clinic/Hospital/Urgent Care Hospital stay over 24 hours Unknown

Who treated the employee and where?

Doctor Name:

Hospital/Clinic Name (if applicable):

Address:

Telephone:

Is the employee still being treated for this injury/illness?

Yes No Unknown

If Yes, name and address of treating doctor(s)

Yes No

RETURN TO WORK INFORMATION:

Did the employee stop work because of his/her injury/illness?

Yes No

If Yes, on what date?

Light duty available?

Yes No

Is claimant/employee back to work?

Yes No

Date of return to work:

Full Pay?

Yes No

If No, average gross earnings?

COMMENTS: