Employers Report Of Occupational Injury Or Disease {OIC-WC-2}

Form OIC-WC-2 West Virginia Workers' Compensation Employers' Report of Occupational Injury or Disease PLEASE PRINT OR TYPE Section I Insurer: Employer's Name: Address: City: State: Employer Information Third-Party Administrator: Nature of Business: FEIN: Zip: Telephone: ( ) - Section II Name: (Last): Address: City: Date of Birth: / / State: 6. Sex: (First): Employee Information (M.I.): Occupation/Job Title: Telephone: ( Zip: M Part-Time / F Volunteer / ) - Social Security No.: Marital Status: Injured Employee is (check all that apply): Owner/Partner Officer Full-Time Employee's Occupation/Job Title: Retired ­ Date Retired: Section III Date of Injury or Last Exposure: Date Employer Notified of Injury or Disease: / / / / Information Regarding Injury or Disease Time: a.m. p.m. Witnesses to Injury: Supervisor to whom Injury or Disease Reported: / Yes / No Address or location where injury If Injury was Fatal, Indicate Date of Death: Did Injury Occur on Employer's Property? occurred: What was the Employee Doing when Injury Occurred (loading truck, walking down stairs, etc.): How did the Injury or Disease Occur (be specific; include time that employee began work on the date of injury, any equipment, tools, substances or objects connected to the injury; attach additional sheet if necessary): Nature of Injury or Disease (cut, bruise, strain, etc.): Body Part(s) Injured: Are You Aware of, or Do You Suspect, a Prior Injury to this Body Part? Do You Have Reason to Question this Injury? Location of Initial Treatment: Yes No Yes No (If "yes," attach a specific explanation to this form). Emergency Room? Yes No Hospitalized? Yes No Section IV Date Hired: / / Number of Work Days Lost: Is Light Duty Available? Yes No Wage and Lost Time Information Last Day Worked After Occupational Injury or Disease: Date of Return to Work: Wage on Date of Injury: $ / / per / / Hours Worked per Week: hour day week month Yes month No Are Wages Being Paid to Injured Employee During Disability? Yes No Daily rate of pay on the date of injury: $ If Employee has Returned to Work, is it Alternative or Modified Work? hour day week If "yes," indicate current wage: $ per and best quarter wages of preceding four quarters $ I certify the statements and answers set forth in this section are true and correct to the best of my knowledge. I am aware the law, specifically West Virginia Code §61-3-24e, provides for severe penalties if I knowingly certify a false report or statement and/or withhold a material fact regarding any information requested. I acknowledge the provisions of the aforementioned code and the severe penalties for knowingly with fraudulent intent aiding or abetting anyone in securing or attempting to secure benefits to which he or she is not entitled. Print Name: Signature: _____________________________________________ Title: Date: _______/________/________ American LegalNet, Inc. www.FormsWorkFlow.com