First Report Of Employee Injury Illness {34401}

INSTRUCTIONS General Instructions: 1. Please enter information into all of the areas of the First Report form, except the boxes at the top right corner of the form which is for office use only. 2. Enter all dates in MM/DD/YY format. 3. Please return completed form electronically by an approved EDI process. 4. For answers to questions, please call (317) 232-3808. Definitions: AGENT NAME AND CODE NUMBER: Enter the name of your insurance agent and his / her code number if known. This information can be found on your insurance policy. ALL EQUIPMENT, MATERIALS OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR EXPOSURE OCCURRED: List anything the employee was using, applying, handling or operating when the injury or exposure occurred. If the injury involves a fall, indicate any surfaces and / or objects the claimant fell on and where they fell from. Enter "NA" if no equipment, materials or chemicals were being used (e.g. Acetylene cutting torch, metal plate, etc.). AVG WG/WK: Claimant's average weekly wage, calculated by totaling the latest 52 weeks of wages (including overtime, tips, etc.) and dividing by 52. CLAIMS ADMINISTRATOR: Enter the name of the carrier, third-party administrator, state fund, or self-insured responsible for administering the claim. CONTACT NAME / TELEPHONE NUMBER: Enter the name of the individual at the employer's premises to be contacted for additional information (i.e. Supervisor, HR Person, Nurse, etc.) DATE DISABILITY BEGAN: The first day on which the claimant originally lost time from work due to the occupational injury or disease or as otherwised deigned by statute. DEPARTMENT OR LOCATION WHERE ACCIDENT OR EXPOSURE OCCURRED: If the accident or exposure did not occur on the employer's premises, enter address or location. Be specific (e.g. Maintenance, Client's Office, Cafeteria, etc.). EMPLOYEE STATUS: Indicate the employee's work status from the following choices: Full-time, Part-time, Apprentice Full-time, Apprentice Part-time, Volunteer, Seasonal Worker, Piece Worker, On-Strike, Disabled, Retired, Not Employed or Unknown (you may also abbreviate the above as: (FT, PT, AFT, APT, VO, SW, PW, OS, DI, RE, NE, or UK). HOW INJURY / ILLNESS OCCURRED: Describe the sequence of events leading to the injury or exposure (e.g. Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, he brushed against the hot metal; Worker stepped to the edge of the scaffolding, lost balance and fell six feet to the concrete floor. The worker's right wrist was broken in the fall). NCCI CLASS CODE: A four-digit code classifying the occupation of the claimant. OCCUPATION / JOB TITLE: Enter the primary occupation of the claimant at the time of the accident or exposure. PART OF BODY AFFECTED: Indicate the part of body affected by the injury / illness (e.g. Right forearm, Low Back, etc.) REPORT PURPOSE CODE: 00 = Original First Report of Injury; 02 = Updated or Amended First Report. RTW DATE (Return to Work Date): Enter the date following the most recent disability period on which the employee returned to work. SIC CODE: This is the code which represents the nature of the employer's business which is contained in the Standard Industrial Classification Manual published by the Federal Office of Management and Budget. SPECIFIC ACTIVITY EMPLOYEE ENGAGED IN DURING ACCIDENT / EXPOSURE: Describe the specific activity the employee was engaged in during the accident or exposure (e.g. Cutting metal plate for flooring, sanding ceiling woodwork in preparation for painting). TYPE OF INJURY / ILLNESS: Briefly describe the nature of the injury or illness (e.g. Contusion, Laceration, Fracture, etc.) WORK PROCESS THE EMPLOYEE WAS ENGAGED IN DURING ACCIDENT / EXPOSURE: Enter "NA" if employee was not engaged in a work process, such as if walking down the hallway (e.g. Building maintenance). American LegalNet, Inc. www.FormsWorkFlow.com INDIANA WORKER'S COMPENSATION FIRST REPORT OF EMPLOYEE INJURY, ILLNESS State Form 34401 (R10 / 1-02) FOR WORKER'S COMPENSATION BOARD USE ONLY Jurisdiction Jurisdiction claim number Process date Please return completed form electronically by an approved EDI process. PLEASE TYPE or PRINT IN INK NOTE: Your Social Security number is being requested by this state agency in order to pursue its statutory responsibilities. Disclosure is voluntary and you will not be penalized for refusal. EMPLOYEE INFORMATION Social Security number Date of birth Sex Occupation / Job title NCCI class code Employee status Male Name (last, first, middle) Address (number and street, city, state, ZIP code) Female Unknown Date hired Hrs / Day Days / Wk State of hire Avg Wg / Wk Marital status Unmarried Married Separated Unknown Number of dependents Paid Day of Injury Salary Continued Wage $ Per Hour Year SIC code Telephone number (include area Day Other Week Month EMPLOYER INFORMATION Name of employer Employer ID# Location number Insured report number Address of employer (number and street, city, state, ZIP code) Employer's location address (if different) Telephone number Carrier / Administrator claim number OSHA log number Report purpose code Actual location of accident / exposure (if not on employer's premises) CARRIER / CLAIMS ADMINISTRATOR INFORMATION Name of claims administrator Address of claims administrator (number and street, city, state, ZIP code) Carrier federal ID number Check if appropriate Self Insurance Policy / Self-insured number Telephone number Insurance Carrier Third Party Admin. Code number Policy period From Name of agent To Date of Inj./ Exp. Time of occurrence OCCURRENCE / TREATMENT INFORMATION Type of injury / exposure AM PM Date employer notified Cannot be determined Date disability began Part of body Type code Last work date Time workday began Date of death Part code Telephone number RTW date Injury / Exposure occurred on employer's premises? Yes No Name of contact Department or location where accident / exposure occurred 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 occurred. Describe the sequence of events and include any relevant objects or substances. Cause of injury code Name of physician / health care provider Hospital or offsite treatment (name and address) Name of witness Date prepared Telephone number Title Date administrator notified Telephone number Name of preparer INITIAL TREATMENT No Me