Convenient Forms

Workers Compensation
First Report of Injury or Illness

Employer's Location (If different)
Address:

City:
Zip:

Name:

Address:

City:

Zip:

Phone:

DOB:

Male

Female

Unknown

Marital Status:

Unmarried

Single/Divorced

Separated

Unknown

Date Hired:

State of Hire:

Occupation/Job Title:

Rate:

Average Weekly Wages:

# Days Worked/Week:

Social Security #:

Full Pay for Day of Injury:

Yes No

Did Salary Continue:

Yes No

Occurrence/Treatment
Contact Name:
Phone Number:
Date of Injury/Illness:
Type of Injury/Illness:
Part of Body Affected:
Did Injury/Illness Exposure Occur on Employer's Premises:	Yes No
Time of Occurrence:
AM:	PM:
Last Work Date:
Date Employer Notified:
Date Disability Began:
Department or Location Where Accident or Illness Exposure Occurred:
Specific Activity the Employee was Engaged in When the Accident or Illness Exposure Occurred:
Date Return(ed) to work:
If Fatal, Give Date of Death:
Were Safeguards or Safety Equipment Provided:	Yes No
Where They Used:	Yes No

Physician/Health Care Provider
Name:
Address:

City:
Zip:

Hospital or Offsite Treatment
Name:
Address:

City:
Zip:

Initial Treatment
	No Medical Treatment
	Minor: By Employer
	Minor Clinic/Hosp
	Emergency Care
	Overnight Hospitalization
	Future Major Medical/Lost Time Anticipated

Date Prepared:
Preparer's Name & Title:

Spam Preventer:

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Workers CompensationFirst Report of Injury or Illness