Employers First Report Of Injury Or Occupational Disease {8 DCWC}

Date of This Report District of Columbia Government Office of Workers' Compensation 4058 Minnesota Avenue, N.E. Washington, DC 20019 (202) 671-1000 Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Employee Social Security No. Employer Identification No. Insurer No. EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE Employee Name and Address: Employer Name and Address: Insurer Name and Address: IMPORTANT: Every employer shall file this report as soon as possible after knowledge of an occupational injury or disease to one of its employees, but no later than ten (10) days thereafter. Failure to file this form shall be subject to civil penalty not to exceed $1,000. Date and time of Injury: _________________________________________am/pm? Day of the week?_________________________________ Normal starting time: ____________am/pm? If employee back to work, give date and time: ___________________________________am/pm? At what wage? ___________________________ If fatal, give date of death ___________________________________(file supplement report) Date/time disability began? _______________________________ am/pm? Was the injured paid in full for this day? _____________________ Was the injured given Form No. 7 DCWC? Yes No Foreman/Supervisor____________________________________________________ When did you or the foreman first learn of the injury? ________________________________________________________________________ Male Female DOB: __________ Employee's Telephone No.: ____________________________________________________________ Occupation when injured? _______________________________ Was this his/her regular occupation?________________________________ (Department or branch regularly employed): _______________________________________________________________________________ Was the injured hired in DC? ________________ How long employed by you? ___________________________________________________ Piece or time worker? ________________________________ Hourly wage? _____________ Hours worked/day? _______________________ Daily wages: _________________ Days worked per week: _______________________________ Average weekly earnings:______________ If board and lodging were furnished or gratuities reported in addition to wages, give estimated value per day, week, or month:_______________ Employer's principal business function in DC:______________________________________________________________________________ Employer's Telephone No.: ______________________________________ Insurance Policy No.:____________________________________ Location of plant or place where accident occurred: _________________________________________________________________________ On employer's premises? _____________________________________________________________________________________________ Describe fully the events which resulted in injury or disease, what the employee was doing when injured and type of injury including parts of the body affected: ______________________________________________________________________________________________________ __________________________________________________________________________________________________________________ Name of Witnesses: _________________________________________________________________________________________________ Nature and location of injury (Describe fully): ______________________________________________________________________________ __________________________________________________________________________________________________________________ Attending Physician and Address (If Hospital Involved ­ Indicate):______________________________________________________________ __________________________________________________________________________________________________________________ ________________________________________________________ Name (Please Print or Type) ________________________________________________________ Signature ________________________________________________________ Official Position _______________________________________________ Name of Person Completing Form Form No. 8 DCWC 9-2491 American LegalNet, Inc. www.FormsWorkFlow.com