INDIANA WORKER'S COMPENSATION FIRST REPORT OF EMPLOYEE INJURY, ILLNESS

EMPLOYEE INFORMATION test
Social Security #	Date of birth	Sex Male   Female   Unknown		Occupation/Job title		NCCI class code
Employee's Name (Last, First with Middle Initial)			Marital Status   Married   Separated   Single   Unknown	Date Hired (MM/DD/YYYY)	State of Hire	Employee Status
Employee's Address (Street, City, State, Zip)				Hrs/Day   Days/Wk   Avg Wg/Wk		Pd DOI   Salary Cont.
Telephone number (include area code)			# of dependents	Wage	Per   Hour       Day     Week   Month     Year     Other
EMPLOYER INFORMATION
Name of Employer			Employer's Federal ID #		SIC code	Insd. report no.
Employer's mailing address (Street, City, State Zip)			Location number	Employer's loction address (if different)
			Telephone #
			Carrier/Admin Claim #		Report purpose code
Actual location of accident/exposure (if not on employer's premises)
CARRIER/CLAIMS ADMINISTRATOR INFORMATION
Name of claims administrator				Carrier FID #	Is the employer self-insured? Yes No
Address				Ins. Carrier   TPA	Policy/Self-insured number
Telephone number					Policy Period - From and To
Name of agent			Code number
OCCURENCE/TREATMENT INFORMATION
Date of Inj./Exp.	Time of occurrence(hh:mm am/pm)		Date employer notified	Type of injury/exposure		Type code
Last work date	Time workday began(hh:mm am/pm)		Date disability began	Part of body		Part code
RTW date	Date of death	Did injury occur on premises? Yes No	Name of contact			Telephone #
Department or location where accident/exposure occured				All equipment, materials, or chemicals involved in accident
Specific activity engaged in during accident/exposure				Work process employee engaged in during accident/exposure
How injury/exposure occured. Describe the sequence of events and include any relevant objects or substances.						Cause of injury code
Name of physician/health care provider					Initial Treatment (check one)   No Medical Treatment   Minor: By Employer   Minor: Clinic/Hospital   Emergency Care   Hospital>24 Hours   Future Major Medical/Lost Time
Name of witness			Telephone number	Date administrator notified
Date prepared	Name of preparer		Title	Phone #
Sender Email