Employers Report Of Industrial Injury {WC-1}

Every work injury to an employee causing absence for one day or more or which requires medical services other than first aid treatment must be reported within 7 working days after the injury. Failure to report promptly is a misdemeanor punishable by not more than a $5,000 fine. (Sec 386-95, H.R.S. NOTIFY THE DIVISION IMMEDIATELY IF INJURY RESULTS IN DEATH.) EVERY QUESTION MUST BE ANSWERED FULLY TO AVOID FURTHER CORRESPONDENCE. The law requires the employer to furnish the injured employee a copy of this report. CASE NUMBER WC-1 EMPLOYER'S REPORT OF INDUSTRIAL INJURY IDENTIFICATION SECTION EMPLOYEE NAME ­ LAST FIRST NOTE: DO NOT WRITE IN SHADED BLOCKS M.I. SOC SEC NO DATE OF BIRTH SEX MALE FEMALE MARITAL STATUS MARRIED SINGLE STATE DATE RECEIVED MM ADDRESS ADDITIONAL ADDRESS INFORMATION (C/O) / DD / YY CITY MM / DD / YY ZIP CODE PHONE OCCUPATION DATE HIRED YRS EMP'D CODE YY DEPARTMENT PAYROLL COMP CLASS CODE OCC. CODE MM REGISTERED EMPLOYER / DD / | DBA ADDRESS CITY STATE ZIP CODE PHONE NATURE OF BUSINESS DATE INJURY/ILLNES REPORTED DATE OF INJURY/ILLNESS PREFAB DOL NUMBER DBA WC-2 MM WC-5 / DD / YY MM / DD / YY DETAIL OF INJURY / ILLNESS TIME OF INJURY/ILLNESS TIME OF I/I CODE PLACE OF I/I IF DIFFERENT FROM EMPLOYER'S MAILING ADDRESS CITY STATE ON EMPLOYER'S PREMISES YES SOURCE OF INJURY TIME WORKSHIFT BEGAN AM PM NO EVENT INDUSTRIAL CODE _____AM ____PM HOW DID THIS ACCIDENT OCCUR? (Please describe fully the events that resulted in injury or occupational disease. | | | Tell what happened. Please use separate sheet if necessary) WHAT WAS EMPLOYEE DOING WHEN INJURED? (Please be specific. Identify tools, equipment or material the employee was using) TASK ACTIVITY ACCIDENT FACTOR AOS OBJECT OR SUBSTANCE THAT DIRECTLY INJURED EMPLOYEE (e.g. the machine employee struck against or struck him; the vapor or poison inhaled or swallowed; the chemical that irritated employee's skin. In cases of strains, the object employee was lifting, pulling, etc.) DESCRIBE IN DETAIL THE NATURE OF THE INJURY, ILLNESS AND PART OF THE BODY AFFECTED YES DISFIGUREMENT BURNS NO NATURE OF INJURY PART OF BODY TIME LOST INFORMATION DATE DISABILITY BEGAN WAS EMPLOYEE FURNISHED MEALS OR LODGING? AVG WKLY WAGE IF EMPLOYEE IS BACK TO WORK GIVE DATE WAS EMPLOYEE PAID IN FULL FOR DAY OF INJURY/ ILLNESS? IF EMPLOYEE DIED GIVE DATE HOURLY WAGE MONTHLY SALARY HRS WKED / WK WEIGHING FACTOR MM / DD / YY YES NO MM / DD / YY YES NO MM / DD / YY GIVE NAME AND ADDRESS OF SURVIVORS ON BACK TREATMENT NAME OF PHYSICIAN OBTAIN NAME OF TREATING PHYSICIAN FROM EMPLOYEE ADDRESS PHYSICIAN I.D. CODE NAME OF MEDICAL FACILITY ADDRESS INPATIENT OVERNIGHT? EMERGENCY ROOM ONLY? CARRIER I.D. YES NO INSURANCE NAME OF WC INSURANCE CARRIER NAME OF ADJUSTING COMPANY IF LIABILITY DENIED ­ WHY? IS LIABILITY DENIED? YES POLICY NO. POLICY PERIOD ADJUSTER I.D. MEDICAL DEDUCTIBLE NO ADJUSTER NAME CARRIER CASE NO. SIGNATURE TITLE DATE MM / DD / YY WC-1 (Rev. SEPT/16) American LegalNet, Inc. www.FormsWorkFlow.com