5 WORKERS' COMPENSATION FIRST REPORT OF INJURY OR ILLNESS REPORT PURPOSE CODE (NAME & ADDRESS INCL. ZIP) CARRIER/ADMINISTRATOR CLAIM NUMBER EMPLOYER JURISDICTION CLAIM NUMBER JURISDICTION INSURED REPORT NUMBER LOCATION #: PHONE # EMPLOYERS LOCATION ADDRESS (IF DIFFERENT) EMPLOYER FEIN SIC CODE CARRIER/CLAIMS ADMINISTRATOR POLICY PERIOD TO CHECK IF APPROPRIATE SELF INSURANCE CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO.) CARRIER (NAME, ADDRESS & PHONE NO.) CARRIER FEIN POLICY/SELF-INSURED NUMBER ADMINISTRATOR FEIN AGENT NAME & CODE SOCIAL SECURITY NUMBER DATE OF BIRTH DATE HIRED STATE OF HIRE NAME (LAST, FIRST, MIDDLE) OCCUPATION/JOB TITLE EMPLOYMENT STATUS NCCI CLASS CODE ADDRESS (INCL. ZIP) SEX UNKNOWN MALE FEMALE PHONE MARITAL STATUS UNMARRIED U U M s S K K M F U SINGLE/DIVORCED MARRIED SEPARATED UNKNOWN # DAYS WORKED/WEEK MONTH DAY FULL PAY FOR DAY OF INJURY? DID SALARY CONTINUE? RATE PER: WEEK OTHER: OCCURRENCE/TREATMENT LAST WORK DATE DATE EMPLOYER NOTIFIED DATE DISABILITY BEGAN AM PM TIME OF OCCURRENCE DATE OF INJURY/ILLNESS AM PM TIME EMPLOYEE BEGAN WORK CONTACT NAME/PHONE NUMBER TYPE OF INJURY/ILLNESS PART OF BODY AFFECTED DID INJURY/ILLNESS EXPOSURE OCCUR ON EMPLOYER'S PREMISES? YES NO TYPE OF INJURY/ILLNESS CODE PART OF BODY AFFECTED CODE DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED EQUIPMENT MATERIALS OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL CAUSE OF INJURY CODE WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? WERE THEY USED? IF FATAL. GIVE DATE OF DEATH DATE RETURN(ED) TO WORK INITIAL TREATMENT HOSPITAL (NAME & ADDRESS) PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS) 0 1 2 3 4 NO MEDICAL TREATMENT MINOR: BY EMPLOYER MINOR CLINIC/HOSP EMERGENCY CARE WITNESSES (NAME & PHONE #) HOSPITALIZED > 24 HRS FUTURE MAJOR MEDICAL/ LOST TIME ANTICIPATED PHONE NUMBER PREPARER'S NAME & TITLE DATE PREPARED DATE ADMINISTRATOR NOTIFIED SEE BACK FOR INSTRUCTIONS IAIABC IA-1 (4/96) REPRINTED WITH PERMISSION OF IAIABC YES YES NO NO YES YES NO NO EMPLOYEE/WAGE WORKERS' COMPENSATION - FIRST REPORT OF INJURY EMPLOYER'S INSTRUCTIONS GENERAL INFORMATION EMPLOYER (NAME & ADDRESS INCL ZIP) - The name and address of the enti- ty employing or statutorily responsible for the employee. DID SALARY CONTINUE - State whether employee's salary was continued by the employer in lieu of compensation benefits. OCCURRENCE/TREATMENT INFORMATION SIC CODE - The code which represents the nature of the employers business which is contained in the Standard Industrial Classification Manual published by the Federal Office of Management and Budget. TIME EMPLOYEE BEGAN WORK - The time employee began work on date of injury. EMPLOYER FEIN - Employers Federal Employer Identification Number. CARRIER/ADMINISTRATOR CLAIM NUMBER - Carrier's claim or file number. DATE OF INJURY/ILLNESS -The date employee was injured. TIME OF OCCURRENCE - The time employee was injured. REPORT PURPOSE CODE - A code used with Electronic Data Interchange to define the specific purpose of the report. (Original, Cancel, Change, Correction) JURISDICTION - State in which you are filing the claim (Mississippi). LAST WORK DATE - The date employee last worked following the injury. DATE EMPLOYER NOTIFIED - The date on which the employer was notified of the injury. JURISDICTION CLAIM NUMBER - Number assigned to claim by Mississippi Workers' Compensation Commission (to be completed by MWCC). DATE DISABILITY BEGAN -The date on which employee began losing time. CONTACT NAME/PHONE NUMBER - Name and phone number of employer rep- resentative to be contacted for further information. INSURED REPORT NUMBER - The number, if any, used by the employer to iden- tify the claim. TYPE OF INJURY/ILLNESS - Briefly describe the nature of the injury or illness, (e.g., Lacerations to the forearm). EMPLOYER'S LOCATION ADDRESS (IF DIFFERENT) - The name and address of the employers facility where the employee was employed at the time of injury, if different from above. PART OF BODY AFFECTED - Indicate the part of body affected by the injury/ill- ness, (e.g., Right Forearm, lower back). LOCATION #/ PHONE # - The number, if any, assigned by the employer to identi- ty its location where the injury occurred and the phone number. DID INJURY/ILLNESS EXPOSURE OCCUR ON EMPLOYER'S PREMISES - Mark yes or no as applicable. CARRIER (NAME, ADDRESS & PHONE NO) - The licensed business entity issu- ing the contract of insurance and assuming financial responsibility for the claim on behalf of the employer. TYPE OF INJURY/ILLNESS CODE - The NCCI code which corresponds to the nature of the injury or illness. (NCCI Table 8: Nature of Injury Codes) PART OF BODY AFFECTED CODE - The NCCI code which corresponds to the part of the body injured. (NCCI Table 7: Part of Body Codes) POLICY PERIOD - The date that the contract/policy under which the claim occurred began and expired. DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED - Be specific (e.g., Maintenance Department or Client's office at 452 Monroe Street, Washington, D.C. 26210). If the accident or illness exposure did not occur on the employer's premises, enter address or location. CHECK IF APPROPRIATE (SELF-INSURANCE) - An indicator that identifies the employer as one who retains the risks arising from their operations and bears the financial responsibility. A jurisdictionally approved or acknowledged employer, group fund, or association assuming financial risk and responsibility for their employees worker's compensation claims. ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED - List all of the equip- ment, materials, and/or chemicals the employee was using, applying, handling or CLAIMS ADMINISTRATOR - The business entity providing claim services on behalf of the carrier, or self-insured. The name of the carrier, third party administra- tor, state fund, or self-insured responsible for administering the claim. operating when the injury or illness occurred. Be specific, for example: decorator's scaffolding, electric sander, paintbrush, and paint. Enter ''NA" for not applicable if no equipment, materials, or chemicals were being used. CARRIER FEIN - Carrier's Federal Employer Identification Number. POLICY/SELF-INSURED NUMBER - The number assigned by the carrier to the insurance contract/policy for the employer; or any similar number assigned to a self- SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCI- DENT OR ILLNESS EXPOSURE OCCURRED - Describe the specific activity the employee was engaged in when the accident or illness exposure occurred, such as sanding ceiling woodwork in preparation for painting. insured employer. ADMINISTRATOR FEIN - Federal Employer Identification Number of Administrator. WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED - Describe the work process the employee was engaged in when the accident or illness exposure occurred, such as building maintenance. Enter ''NA'' for not applicable if employee was not engaged in a work process (e.g., walking along a hallway). AGENT NAME & CODE NUMBER - The name of the insurance agent and the agents code number if known. This information should be found in the insurance policy. EMPLOYEE/WAGE INFORMATION NAME (LAST, FIRST, MIDDLE) - Employee's legally recognized name. HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL - Describe how the injury or illness/abnormal health condition occurred. Include the sequence of events and name any objects or substance that directly injured the employee or made the employee ill. For example: Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The worker's right wrist was broken in the fall. ADDRESS - The mailing address used by the employee. PHONE - A telephone number where the employee can be reached. DATE OF BIRTH -The date the employee was born. SOCIAL SECURITY NUMBER - A number assigned by the Social Security Administration used to identify the employee. CAUSE OF INJURY CODE - The NCCI code which identifies the cause of injury. (NCCI Table 9: Cause of Injury Codes) DATE HIRED - The date the injured worker began his/her employment with the employer under which the claim is being filed. If there have been multiple periods of employment, this would be the beginning date of the current employment period. DATE RETURN(ED) TO WORK - Enter the date following the most recent disabili- ty period on which the employee returned to work. STATE OF HIRE - State where employee was hired. IF FATAL, GIVE DATE OF DEATH - Date of death of employee SEX - The code which indicates the sex of the employee. WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED/WERE THEY USED - Check applicable ''yes" or ''no" box. MARITAL STATUS - The code which indicates the marital status of the employee. OCCUPATION/JOB TITLE - This is the primary occupation of the employee at the time of the accident or exposure. PHYSICIAN/HEALTH CARE PROVIDER (NAME AND ADDRESS) - The name and address of the physician or health care professional providing initial treatment. EMPLOYMENT STATUS - Indicate the employee's work status. The valid choices are: Full-time, Part-Time, Not Employed, On Strike, Disabled, Retired, Unknown, Apprenticeship Full-Time, Apprenticeship Part-Time, Volunteer, Seasonal, or Piece Worker. HOSPITAL (NAME AND ADDRESS) - The name and address of the hospital where employee was treated (if applicable). INITIAL TREATMENT - Check applicable choices. WITNESSES (NAME& PHONE #)-The name(s) and phone number(s) of anyone who witnessed the accident. NCCI CLASS CODE - A code which corresponds to the primary occupation which the employee was engaged at the time of accident/injury, or injurious exposure. Codes are found in the NCCI BASIC MANUAL FOR WORKERS' COMPENSATION DATE ADMINISTRATOR NOTIFIED - The date the carrier or claims administrator processing the claim received notice of the injury AND EMPLOYERS LIABILITY INSURANCE. RATE - The reported employee's wage rate at the time of injury. DATE PREPARED - The date this report was prepared. PREPARER'S NAME &TITLE -The name and title of the person who prepared this report. # DAYS WORKED/ WEEK - The number of days worked by the employee in a week. FULL PAY FOR DAY OF INJURY - State whether employee was paid his full wages on the injury date. PHONE NUMBER - The phone number of the person who prepared this report.