First Report Of Injury And Occupational Disease

OSHA Log Case # First Report of Injury or Occupational Disease Montana Department of Labor and Industry PO Box 8011 Helena, MT 59604-8011 Adjuster Date Stamp Worker LAST NAME MAILING ADDRESS PHONE NUMBER EDUCATION LESS THAN HIGH SCHOOL GED OR HIGH SCHOOL DIPLOMA BEYOND HIGH SCHOOL GENDER MALE UNKNOWN FIRST NAME M.I. CITY DATE OF BIRTH SOCIAL SECURITY NUMBER STATE POSTAL CODE NUMBER OF DEPENDENTS FEMALE MARITAL STATUS MARRIED SEPARATED WIDOWED, DIVORCED, SINGLE, UNMARRIED UNKNOWN Wages GROSS EARNINGS FOR FOUR PAY PERIODS PRECEDING THE INJURY DATE/AMOUNT / DATE/AMOUNT / DATE/AMOUNT EMPLOYMENT STATUS NUMBER OF DAYS WORKED PER WEEK WAGE FULL TIME PART TIME SEASONAL PIECE WORKER VOLUNTEER OTHER IN ADDITION TO GROSS EARNINGS CITED ABOVE WORKER RECEIVED ESTIMATED VALUE IF ANY ROOM & BOARD OVERTIME BONUS COMMISSIONS OTHER WORKED NEXT SCHEDULED SHIFT YES NO OFF WORK MORE THAN 4 WORK DAYS YES NO NOT SURE DATE LAST WORKED DATE HIRED / WAGE PERIOD HOUR DATE/AMOUNT WEEK MONTH / DAY BI-WEEKLY TIME EMPLOYEE BEGAN WORK FULL WAGES PAID FOR DATE OF INJURY YES NO SALARY CONTINUED YES NO DATE OF RETURN TO WORK Accident Description JOB TITLE CAUSE OF INJURY DATE DISABILITY BEGAN ACCIDENT ON EMPLOYER'S PREMISES YES NO DATE EMPLOYER NOTIFIED DESCRIPTION OF ACCIDENT CAUSE CODE PART OF BODY PART CODE NATURE OF INJURY NATURE CODE DATE OF INJURY TIME OF INJURY DATE OF DEATH ACCIDENT ADDRESS OR LOCATION CITY STATE ACCIDENT REPORTED TO NAMES OF WITNESSES 1) POSTAL CODE 2) 3) SAFETY EQUIPMENT PROVIDED YES NO SAFETY EQUIPMENT USED YES NO Medical ATTENDING PHYSICIAN'S NAME HOSPITAL NAME ADDRESS ADDRESS NO TREATMENT STATE STATE POSTAL CODE POSTAL CODE PHONE NUMBER PHONE NUMBER TREATMENT ON-SITE BY EMPLOYER OR MEDICAL STAFF CLINIC/DR. OFFICE TYPE OF INITIAL MEDICAL TREATMENT RECEIVED HOSPITAL>24 HOURS EMERGENCY ROOM/URGENT CARE Signature "This is my claim for workers' compensation benefits due to the on-the-job injury, occupational disease, or death of the above named worker. I understand that signing this claim for compensation authorizes the release to the workers' compensation insurer (and its agents) and to the Montana Uninsured Employers' Fund of: Social Security records; rehabilitation records; and all health care information (medical records, pursuant to HIPAA, Public Law 104-191, 42 USC section 1301, et. seq., and section 39-71-604, MCA), that are directly relevant to the claimed injury, disease, or death. I also understand that if I obtain or exert unauthorized control over workers' compensation benefits to which I am not entitled, I may be prosecuted for theft." Signature of Injured Worker or Beneficiary Date Employer EMPLOYER NAME MAILING ADDRESS CITY DOING BUSINESS AS STATE POSTAL CODE NATURE OF BUSINESS NAICS CODE FEDERAL EMPLOYER IDENTIFICATION NUMBER (TAX ID) PHONE NUMBER SELF-INSURED? YES NO LOCATION OF OPERATION, IF DIFFERENT FROM MAILING ADDRESS EMPLOYER IS A SOLE PROPRIETORSHIP PARTNERSHIP CORPORATION LIMITED LIABILITY COMPANY INJURED WORKER IS A SOLE PROPRIETORSHIP PARTNERSHIP CORPORATION LIMITED LIABILITY COMPANY A MEMBER OF THE EMPLOYER'S (SOLE PROPRIETOR OR PARTNER) FAMILY LIVING IN THE EMPLOYER'S HOUSEHOLD NO WAS WORKER INJURED WHILE IN YOUR EMPLOY YES NO DO YOU HAVE ANY REASON TO QUESTION THIS ACCIDENT? YES IF YES, PLEASE EXPLAIN FULLY. USE SEPARATE SHEET IF YOU NEED ADDITIONAL SPACE Prepared By PAYROLL CLASSIFICATION CODE UNDER WHICH YOU REPORT EMPLOYEE'S WAGES Official Title Phone Number Date AUTHORIZED EMPLOYER'S SIGNATURE_______________________________________________ DATE__________________________ Insurer CLAIM ADMINISTRATOR CLAIM NUMBER CLAIM ADMINISTRATOR'S NAME DATE REPORTED TO CLAIM ADMINISTRATOR CLAIM ADMINISTRATOR ADDRESS THE ABOVE INFORMATION IS CORRECT WITH THE FOLLOWING EXCEPTIONS (ATTACH EXTRA SHEETS IF BOX AT RIGHT IS CHECKED) CLAIM ADMINISTRATOR FEIN INSURER NAME POLICY NUMBER ERD ­ 991 (Rev. 05/2016 DE) INSURER FEIN POLICY EFFECTIVE DATE POLICY EXPIRATION DATE American LegalNet, Inc. www.FormsWorkFlow.com