Employers First Report Of Injury {WC1}

See instructions on reverse side before completing form. COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION EMPLOYER'S FIRST REPORT OF INJURY Employee's name (first, middle, last) Employee's street address Birth date Marital status Married Separated Single Unknown Date of hire Social Security # City Occupation Male Female Employee's home phone # ( ) State Zip code Employment status Full time Part time Other Unknown Employer's phone # ( ) State Zip code OSHA Log # / / / / Employer's Federal ID # City For Division use only SOI POB NOI Employer's name Employer's mailing address Average weekly wage at time of injury $___________________ (see instructions on reverse side) Check box if employee receives Tips Meals Room Health insurance Were full wages paid for the DOI? Yes No Injury time Last day worked Check if these benefits are included in AWW Is the employer self-insured? Yes No Injury/Illness Time employee began work date ____ ___ a.m. ____ ___ a.m. // / / / / / ____ ___ p.m. ____ ___ p.m. (See instructions on reverse side) unknown Did injury cause Name, relationship, and address of closest dependent if injury caused If so, death? death date of death Yes No Coder Tips Meals Room Health insurance Are wages continued per C.R.S. 8-42-124? 1 Yes No Date employer Date disability Date returned to notified began work / / / / / Injury occurred because of Intoxication Safety violation Not applicable Tell us the part of body that was affected What was the employee doing just before the accident occurred?3 Tell us how the injury occurred4 Tell us the nature of the injury/illness2 What object or substance directly harmed the employee? 5 Did injury occur on premises? Yes No Injury site address/ 9-digit zip code Initial treatment (check one) Was the employee hospitalized overnight as an in-patient? Names of witnesses Emergency room Yes No None Hospital >24 hrs Minor on-site Clinic/hospital Name of employer representative notified Name and address of facility where treated Phone # ( ) Date completed Name and address of treating doctor or other health care professional Completed by (name) Title / / The following is to be completed by the insurer prior to filing with the Division of Workers' Compensation. Name of insurance company Name of third party administrator (if applicable) Adjuster name Policy # Carrier claim # Address Address Adjuster phone # Date insurer received first report Block # Adj. Code American LegalNet, Inc. www.USCourtForms.com / WC 1 Rev 01/06 / INSTRUCTIONS This form contains all items requested on OSHA Form No. 301, "Injuries & Illnesses Incident Report" General · All injuries no matter how trivial must be reported to your insurance company. · All injuries or occupational diseases which result in lost time from work in excess of three shifts or calendar days, or in permanent physical impairment, must be reported to your insurance carrier on this form within ten days after notice or knowledge of the injury or disease. Fatalities must be reported to your insurance carrier immediately. · Forms should be typed or printed legibly. · All questions must be answered completely to meet requirements of the Colorado Workers' Compensation Act and to conform to the OSHA requirements for Form No. 301. · The employer has the right in the first instance, to select the physician who attends the injured employee. Calculation of Average Weekly Wage · Determine the weekly wage rate. · Add the average weekly amount of any overtime wages, tips or commissions. · Add the average weekly value of any board, rent, housing, or lodging provided by the employer if the employer will not be paying such benefit during the period of disability. · If the employee is covered by group health insurance and the employer does not continue the employee's health insurance coverage during the period of disability, add the employee's cost of conversion to a similar or lesser insurance plan and include this cost in the average weekly wage computation. · Compute the total from the above categories and insert in the Average weekly wage at time of injury field. Injury Date Information In the case of an occupational disease, use the date of the last injurious exposure. Notes Are Wages continued per C.R.S. 8-42-124?1 (Subject to application with and approval of the Director of the Colorado Division of Workers' Compensation) 1 Any employer who, by separate agreement, working agreement, contract of hire, or any other procedure, continues to pay a sum in excess of the temporary total disability benefits to an employee temporarily disabled as a result of a work related injury or disease, and has not charged the employee with any earned vacation leave, sick leave, or other similar benefits, shall be reimbursed if insured by an insurance carrier or shall take credit if self-insured, to the extent of all moneys that such employee may be eligible to receive as compensation for temporary partial or temporary total disability subject to the approval of the Director of the Colorado Division of Workers' Compensation. Injury Description (Tell us the part of body that was affected. Tell us the nature of the injury/illness 2; What was the employee doing just before the accident occurred? 3; What happened? 4; What object or substance directly harmed the employee?5) 2 3 4 5 Be more specific than ""hurt", "pain", or "sore." Examples: "strained back"; "chemical burn, hand"; "carpal tunnel syndrome." Describe the activity, as well as the tools, equipment or material the employee was using. Be specific. Examples: "climbing a ladder while carrying roofing materials"; "spraying chlorine from hand sprayer"; or "daily computer key-entry." Tell us how the injury occurred. Examples: "When ladder slipped on wet floor, worker fell 20 feet"; "Worker was sprayed with chlorine when gasket broke during replacement"; "Worker developed soreness in wrist over time." Examples: "concrete floor"; "chlorine"; "radial arm saw." If this question does not apply to the incident, leave it blank Notices You are hereby notified that if a child support obligation is owed, compensation benefits may be attached and payment of the child support obligation may be withheld and forwarded to the obligee pursuant to sections 8-42-124 and 26-13-122(4), C.R.S. YOU ARE FURTHER NOTIFIED that you must provide written notice of any award for social security, pension, disability or other source of income that might reduce your compensation benefits. This no