Instructions for successful submission:
1. Date fields must be entered in the format MM/DD/YY.
    Example: August 5, 1998 would be entered 08/05/98 (not 8/5/1998 or 8-5-98).
2. Time fields must be entered in the format HH:MM.
    Example: 08:00 (not 800 or 8:00).
3. Do not use dollar signs or commas in dollar amount fields. Decimals are okay.
    Example: 9.52 (not $9.52) or 25800 (not 25,800).
4. If you are unsure what to enter in a field, or the field does not apply, leave it blank.
    Do not put zeros or "N/A" in date fields.
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Employer
Address
 
City
State Zip Code
Phone
Employer's location address, if different:
Address
 
City
State Zip Code
Location Number
Policy Number
Federal Tax Number
SIC Code
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Last Name
First Name
Middle Name
Social Security
Number		 - -
Address
 
City
State Zip Code
Home Phone
Work Phone Ext.
Date of Birth MM/DD/YY
Gender
Marital Status
Number of Dependents
Date Hired MM/DD/YY
Hire State
Occupation
Employment Status
NCCI Class Code
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Wage Rate $ per
Number of Days Worked per Week
Average Weekly Wage $
Paid on Day of Injury?Yes No
Did Salary Continue?Yes No
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Date of Injury MM/DD/YY
Time of Injury HH:MM
Last Work Date MM/DD/YY
Time Employee
Began Work		 HH:MM
Date Disability BeganMM/DD/YY
Date Employer NotifiedMM/DD/YY
Contact Name
Phone Ext.
Part of Body
Type of Injury/Illness
Did injury occur on employer's premises?
Yes No
Location where accident occurred:
Location
Address
 
City
State Zip Code
Specifically describe injury and how it occurred:

Equipment, materials, chemicals employee was using when accident occurred:

Safety equipment provided?Yes No
If yes, was it used? Yes No
Specific activity employee was engaged in when the accident or illness occured

Work process employee was engaged in when the accident of illness occurred:
Cause of Injury
Date returned to work MM/DD/YY
If fatal, date of death MM/DD/YY
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Physician
Address
 
City
State Zip Code
Hospital
Address
 
City
State Zip Code
Initial Treatment:
No Treatment
Minor by Employer
Minor by Clinic/Hospital
Emergency Care
Hospitalized for more than 24 hours
Major Medical/Lost Time Anticipated
 
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Witness
Phone Ext.
Preparer
Title
Phone Ext.
E-Mail Address
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Has employee injured this part of body before?
Yes No
If yes, give details:


Is the injured worker an officer or partner?
Yes No
 
Accident Cause Code
Was accident caused by machine or product failure?
Yes No
If yes, explain:

Did injury occur while performing regular duties?
Yes No
Was injury caused by anyone other than the employee, a coworker, or employer?
Yes No
If yes, explain:
Do you doubt the validity of this claim?
Yes No
If yes, explain: