COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION EMPLOYER'S FIRST REPORT OF INJURY

Employee's First and Middle Name	Employee's Last Name		Social Security #	Sex Male Female	Home Phone #	OSHA Log #
Employee's Street Address			City	State	Zip Code	For Division Use Only
Birth Date (MM/DD/YYYY)	Marital Status   Married   Separated   Single   Unknown	Date of Hire (MM/DD/YYYY)	Occupation	Employment Status   Full Time       Part Time   Other             Unknown		SOI
Employer's Name			Employer's Federal ID #		Employer's Phone #	POB
Employer's mailing address			City	State	Zip Code	NOI
Average weekly wage at time of injury	Check box if employee recieves   Tips           Meals   Room         Health Insurance		Check if these benefits are included in AWW   Tips           Meals   Room         Health Insurance			Coder
Is the employer self-insured? Yes No		Were full wages paid for the DOI? YesNo		Are wages continued per C.R.S. 8-42-124? YesNo
Injury/Illness Date	Time Employee Began Work (hh:mm am/pm)	Injury Time (hh:mm am/pm)	Last day worked	Date Employer Notified	Date Disability Began	Date Returned to Work
Did injury cause death? Yes No	If so, date of death	Name, relationship, and address of closest dependent if injury caused death			Injury occurred because of Intoxication Safety Violation Not Applicable
Tell us the part of body that was affected				Tell us the nature of the injury/illness
What was the employee doing just before the accident occured?
Tell us how the injury occurred				What object or substance directly harmed the employee
Did injury occur on premises? Yes No	Injury Site Addres/9-Digit Zip Code	Initial Treatment (check one)   None                Emergency Room   Minor On-Site     Hospital>24 Hours   Clinic/Hospital			Was the employee hospitalized overnight as an in-patient? Yes No
Names of Witnesses				Name of Employer Representative Notified
Name and Address of Treating Doctor or Other Health Care Professional				Name and Address of Facility Where Treated
Completed By (Name)			Title		Phone #	Date Completed
The following is to be completed by the insurer prior to filing with the Division of Workers' Compensation.
Name of Insurance Company				Address
Name of Third Part Administrator (if applicable)				Address
Adjuster Name				Adjuster Phone #
Policy #	Carrier Claim #		Date Insurer Received First Report		Block #	Adj. Code
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