First Report Of Injury {12A}

COURT WORKERS' FIRST COUNTY .OF. . . . COMPENSATION. . . . . . . . . . . . REPORT OF INJURY . .AND ADDRESS.INCL. ZIP) ...... .. ................... ..... . CARRIER/ADMINISTRATOR.CLAIM NUMBER EMPLOYER (NAME : Index No. JURISDICTION . OR ILLNESS REPORT PURPOSE CODE : JURISDICTION CLAIM NUMBER Calendar No. : : : INSURED REPORT NUMBER Plaintiff(s) SIC CODE EMPLOYER FEIN JUDICIAL SUBPOENA LOCATION # PHONE # -against- EMPLOYER'S LOCATION ADDRESS (IF DIFFERENT) CARRIER/CLAIMS ADMINISTRATOR CARRIER (NAME, ADDRESS AND PHONE NO.) POLICY PERIOD EMPLOYER'S LOCATION ADDRESS (IF DIFFERENT) : TO Defendant(s) : ...................................................... CHECK IF APPROPRIATE SELF INSURANCE CARRIER FEIN POLICY/SELF-INSURED NUMBER ADMINISTRATOR FEIN THE PEOPLE OF THE STATE OF NEW YORK AGENT NAME & CODE NUMBER TO EMPLOYEE/WAGE NAME DATE OF BIRTH SOCIAL SECURITY NUMBER DATE HIRED STATE OF HIRE ADDRESS (INCL ZIP) GREETINGS: SEX M MALE F FEMALE MARITAL STATUS UNMARRIED U SINGLE/DIVORCED OCCUPATION/JOB TITLE PHONE RATE WE COMMAND YOU, that all U UNKNOWN excuses being laid aside, you and each of you attend before business and M MARRIED S SEPARATED , the Honorable at the Court NCCI CLASS CODE # OF DEPENDENTS K UNKNOWN located at County of in room , on the day of , 20 DAYS,WORKED/WEEK at o'clock in the FOR DAY OF INJURY? at any recessed noon, and FULL PAY DAY MONTH YES NO PER: or adjourned date, to WEEK testify and OTHER evidence as a witness in this action on the part of CONTINUE? give the DID SALARY YES NO AM PM DATE OF INJURY/ILLNESS TIME OF OCCURRENCE AM PM LAST WORK DATE DATE EMPLOYER NOTIFIED DATE DISABILITY BEGAN EMPLOYMENT STATUS OCCURRENCE/TREATMENT TIME EMPLOYEE BEGAN WORK CONTACT NAME/PHONE Your failure to comply with this TYPE OF INJURY/is punishable as a contempt of OF BODY and will make you liable to subpoena ILLNESS PART court AFFECTED the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. TYPE OF INJURY/ ILLNESS CODE PART OF BODY AFFECTED CODE YES DID INJURY/iLLNESS EXPOSURE OCCUR ON EMPLOYER'S PREMISES? NO Witness, Honorable Court in County, , one of the Justices of the day of ALL EQUIPMENT MATERIALS OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED , 20 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 (Attorney must sign above and type name below) HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURE THE EMPLOYEE OR MADE THE EMPLOYEE ILL CAUSE Of INJURY CODE Attorney(s) for DATE RETURNED) TO WORK IF FATAL, GIVE DATE OF DEATH WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? WERE THEY USED? PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS) HOSPITAL (NAME & ADDRESS) YES YES NO NO INITIAL TREATMENT Office and P.O. Address 0 NO MEDICAL TREATMENT 1 MINOR: BY EMPLOYER 2 MINOR CLINIC/HOSP 3 EMERGENCY CARE WITNESSES (NAME & PHONE #) DATE ADMINISTRATOR NOTIFIED DATE PREPARED PREPARER'S NAME & TITLE SEE BACK FOR IMPORTANT STATE INFORMATION/SIGNATURE REPRINTED WITH PERMISSION OF IAIABC Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 4 HOSPITALIZED > 24 HRS. FUTURE MAJOR MEDICAL/ 5 LOST TIME ANTICIPATED PHONE NUMBER American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. EMPLOYER'S INSTRUCTIONS Calendar No. DO NOT ENTER DATA IN SHADED:FIELDS DATES: Enter all dates in MM/DD/YY format. JUDICIAL contained in the Plaintiff(s) SIC CODE: This is the code which represents the nature of the employers business which is SUBPOENA Standard Industrial Classification Manual published by the Federal Off ice of Management and Budget. -against: CARRIER: The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer of the claimant. : CLAIMS ADMINISTRATOR: Enter the name of the carrier, third party administrator, state fund, or self-insured responsible : for administering the claim. : Defendant(s) AGENT NAME & CODE NUMBER: Enter the name of your insurance agent and his/her code number if known. This : . . . . . . . be . . . . . . . . . . . . . . . . . . . . . . information. can . . .found.on your insurance .policy.. . . . . . . . . . . . . . . . . . . OCCUPATION/JOB TITLE: This is the primary occupation of the claimant at the time of the accident or exposure. EMPLOYMENT STATUS: Indicate the employee's work status. The valid choices are: THE PEOPLE OF THE STATE OF NEW YORK On Strike Disabled Retired Full-Time Part-Time TO Not Employed Unknown Apprenticeship Full-Time Apprenticeship Part-Time Volunteer Seasonal Piece Worker DATE DISABILITY BEGAN: The first day on which the claimant originally lost time from work due to the occupation injury or disease or as otherwise deigned by statute. CONTACT NAME/PHONE NUMBER: Enter the name of the individual at the employers premises to be contacted for additional information. GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court TYPE the Honorable OF INJURY/ILLNESS: Briefly describe the nature ofat the the injury or illness, (eg. Lacerations to the forearm). located at County of PART OF BODY AFFECTED: Indicate the part of body affected by the injury/illness, (eg. Right forearm, lower back). in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned LOCATION WHERE ACCIDENT OR a witness in this action on the part (eg. DEPARTMENT OR date, to testify and give evidence as ILLNESS EXPOSURE OCCURRED:of theMaintenance Department or Client's office at 452 Monroe St., Washington, DC 26210) If the accident or illness exposure did not occur on the employer's premises, enter address or location. Be specific. , Your failure to comply with this EMPLOYEE WAS USING a contempt of court and will make you liable ALL EQUIPMENT, MATERIAL OR CHEMICALS subpoena is punishable as WHEN ACCIDENT OR ILLNESS EXPOSUREto the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a OCCURRED: (eg. Acetylene cutting torch, metal plate) List all of the equipment, materials, and/or chemi