EMPLOYER'S FIRST REPORT OF INJURY OR DISEASE
Department of Workforce Development
Worker's Compensation Division
P.O. Box 7901, Madison, WI 53707
An employer shall report immediately
I. EMPLOYEE DATA
Employee Name (First, Middle, Last)
Social Security Number
Sex
Male
Female
Employee Home Phone No
Employee Street Address
City
State
Zip Code
Occupation
Birthdate
Date of Hire
County and State Where Accident or Exposure Occurred?
II. EMPLOYER DATA
Employer Name
WI Unemployment Ins. Acct No.14. Federal ID Number
Self-Insured?
Yes
No
Nature of Business (Specific Product)
Employer Mailing Address
City
State
Zip Code
Empolyer FEIN
Name of Worker's Compensation Insurance Co. or Self-Insured Employer
Insurer FEIN
Name and Address of Third Pary Administrator (TPA) Used by the insurance Company or Self-Insured Employer
TPA FEIN
WAGE INFORMATION
Wage at Time of Injury
Specifiy per hr, wk, mo, yr, etc
In Addition to Wages,
Check Box(es) if
Employee Received:
Meals
No. of Meals/wk
Room
No. of Days/wk
Tips
Avg Weekly Amt $
Is Worker Paid for Overtime?
Yes
No
If Yes, After How Many Hours of Work Per Week
For the 52 Week Period Prior to the Week the Injury Occurred, Report Below the Number of Weeks Worked in the Same Kind of Work, and the Total Wages, Salary, Commission and Bonus or Premium Earned for Such Weeks.
No of Weeks
Gross Amount Excluding Tips: $
If Piece-Work, No. of Hrs. Exluding Overtime
Start Time
Hours Per Day
Hours Per Week
Days Per Week
Employer's Usual Work Schedule When Injured:
:
AM
PM
Employer's Usual Full-Time Schedule for This Type of Work at Time of Employee's Injury:
Part-Time Employment Information:
Are there Other Part-Time Workers Doing the Same Work With the Same Schedule?
Yes
No
If yes, how many?
# of Full-Time Employees Doing Same Type Of Work:
INJURY INFORMATION
Injury Date
Time of Injury
AM
PM
Last Day Worked
Date Employer Notified
Date Returned to Work
Est Date of Return
Did Injury Cause Death?
Yes
No
Date of Death
Was This a Lost Time or Other Compensable Injury?
Yes
No
Did Injury Occur Because of:
Substance Abuse
Failure to Use Security Devices
Failure to Obey Rules
Was Employee Treated in an Emergency Room?
Yes
No
Was Employee Hospitalized Overnight as an In-Patient?
Yes
No
Name and Address of Treating Practitioner and Hospital
Case Number from the OSHA Log:
Injury Description - Describe Activities of Employee When Injury or Illness Occurred and What Tools, Machinery, Objects, Chemicals, Etc. Were Involved:
What Happended to Cause This Injury or Illness? (Describe How the Injury Occurred)
What Was The Injury or Illness? (State the Part of Body Affected and How It Was Affected)
V.PREPARER DATA
Report Prepared By
Work Phone Number
Position
Date Signed