Workers Compensation First Notice Of Loss EMPLOYER | INSURED INFORMATIONWho Is Submitting This Claim? First Last Mobile PhoneEmail Name Of BusinessInsurance CarrierErie InsuranceTravelers InsuranceAccident FundNationwide InsuranceState AutoOtherPolicy InformationEMPLOYEE INFORMATIONEmployee Name First Last Date of Birth Date Format: MM slash DD slash YYYY Social Security NumberDate Of Hire Date Format: MM slash DD slash YYYY State Of Hire AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Employee Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employee PhoneEmployee Email SexMaleFemaleUnknownMarital StatusUnmarried | Single | DivorcedMarriedSeperatedUnknownNumber Of DependentsOccupation | Job TitleEmployment StatusFull TimePart TimeNot EmployedOn StrikeDisabledRetiredUnknownApprenticeship - Full TimeApprenticeship - Part TimeVolunteerSeasonalPiece WorkerNCCI Class Code (If Known)Wage Rate (Example $X Per Hour)Average Weekly WagesNumber of Days Worked Per WeekFull Pay For Day Of Injury?YesNoDid Salary Continue?YesNoOCCURRENCE | TREATMENTTime Employee Began Work : HH MM AM PM Date Of Injury | Illness Date Format: MM slash DD slash YYYY Time Of Occurrence (approx) : HH MM AM PM Last Work Date Date Format: MM slash DD slash YYYY Date Employer Notified Date Format: MM slash DD slash YYYY Date Disability Began (If Applicable) Date Format: MM slash DD slash YYYY The 1st day on which the claimant originally lost time from work due to the injury/diseaseEmployer Contact First Last Name of the individual at the Employer's Premises to be contacted for additional informationEmployer PhoneType Of InjuryNature of injury or illness (eg. Lacerations to the forearm)Part Of Body AffectedIndicate the part of body (eg. right forearm, lower back)Location Accident | Illness Occurred Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code All Equipment, Material Or Chemicals Employee Was Using When Accident Or Illness Exposure OccurredSpecific Activity The Employee Was Engaged In When The Accident Or Illness Exposure OccurredDescribe the specific activityWork Process The Employee Was Engaged In When Accident Or Illness Exposure OccurredWhat was the employee doing?***How Injury Or Illness / Abnormal Health Condition Occurred. Describe The Sequence Of Events And Include Any Objects Or Substances That Directly Injured The Employee Or made The Employee Ill***Date Returned To Work (If Applicable) Date Format: MM slash DD slash YYYY If Fatal, Give Date Of Death Date Format: MM slash DD slash YYYY Were Safeguards Or Safety Equipment Provided?YesNoWere They Used?YesNoSelect Who The Injured Party Saw For TreatmentPhysician | Healthcare ProviderHospital or Offsite TreatmentNASelect All That ApplyPhysician | Healthcare Provider NamePhysician | Healthcare Provider Contact Person (If Applicable)Physician | Healthcare Provider PhoneHospital | Offsite Treatment Provider PhoneHospital | Offsite Treatment Facility NameHospital | Offsite Treatment Facility Contact Person (If Applicable)Physician | Healthcare Provider Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Hospital | Offsite Treatment Provider Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Initial TreatmentNo Medical TreatmentMinor: By EmployerMinor: Clinic | HospitalEmergency CareOvernight HospitalizationFuture Major Medical / Lost Time AnticipatedUpload Any Files Drop files here or