Workers Compensation First Notice Of Loss

EMPLOYER | INSURED INFORMATION

Who Is Submitting This Claim?

First Last

Mobile Phone

Email

Name Of Business

Insurance Carrier

Policy Information

EMPLOYEE INFORMATION

Employee Name

First Last

Date of Birth

Social Security Number

Date Of Hire

State Of Hire

State

Employee Address

Street Address City State ZIP Code

Employee Phone

Employee Email

Sex

Male
Female
Unknown

Marital Status

Unmarried | Single | Divorced
Married
Seperated
Unknown

Number Of Dependents

Occupation | Job Title

Employment Status

NCCI Class Code (If Known)

Wage Rate (Example $X Per Hour)

Average Weekly Wages

Number of Days Worked Per Week

Full Pay For Day Of Injury?

Yes
No

Did Salary Continue?

Yes
No

OCCURRENCE | TREATMENT

Time Employee Began Work

: HH

MM

Date Of Injury | Illness

Time Of Occurrence (approx)

: HH

MM

Last Work Date

Date Employer Notified

Date Disability Began (If Applicable)

The 1st day on which the claimant originally lost time from work due to the injury/disease

Employer Contact

First Last

Name of the individual at the Employer's Premises to be contacted for additional information

Employer Phone

Type Of Injury

Nature of injury or illness (eg. Lacerations to the forearm)

Part Of Body Affected

Indicate the part of body (eg. right forearm, lower back)

Location Accident | Illness Occurred

Street Address City State ZIP Code

All Equipment, Material Or Chemicals Employee Was Using When Accident Or Illness Exposure Occurred

Specific Activity The Employee Was Engaged In When The Accident Or Illness Exposure Occurred

Describe the specific activity

Work Process The Employee Was Engaged In When Accident Or Illness Exposure Occurred

What 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)

If Fatal, Give Date Of Death

Were Safeguards Or Safety Equipment Provided?

Yes
No

Were They Used?

Yes
No

Select Who The Injured Party Saw For Treatment

Physician | Healthcare Provider
Hospital or Offsite Treatment
NA

Select All That Apply

Physician | Healthcare Provider Name

Physician | Healthcare Provider Contact Person (If Applicable)

Physician | Healthcare Provider Phone

Hospital | Offsite Treatment Provider Phone

Hospital | Offsite Treatment Facility Name

Hospital | Offsite Treatment Facility Contact Person (If Applicable)

Physician | Healthcare Provider Address

Street Address City State ZIP Code

Hospital | Offsite Treatment Provider Address

Street Address City State ZIP Code

Initial Treatment

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EMPLOYER | INSURED INFORMATION

EMPLOYEE INFORMATION

OCCURRENCE | TREATMENT

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