Workers Compensation First Notice Of Loss EMPLOYER | INSURED INFORMATIONWho Is Submitting This Claim? First Last Mobile PhoneEmail Name Of Business Insurance CarrierErie InsuranceTravelers InsuranceAccident FundNationwide InsuranceState AutoOtherPolicy Information EMPLOYEE INFORMATIONEmployee Name First Last Date of Birth MM slash DD slash YYYY Social Security Number Date Of Hire 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 Sex Male Female Unknown Marital Status Unmarried | Single | Divorced Married Seperated Unknown Number Of DependentsOccupation | Job Title Employment Status Full Time Part Time Not Employed On Strike Disabled Retired Unknown Apprenticeship - Full Time Apprenticeship - Part Time Volunteer Seasonal Piece Worker NCCI Class Code (If Known)Wage Rate (Example $X Per Hour) Average Weekly WagesNumber of Days Worked Per WeekFull Pay For Day Of Injury? Yes No Did Salary Continue? Yes No OCCURRENCE | TREATMENTTime Employee Began Work : Hours Minutes AM PM AM/PM Date Of Injury | Illness MM slash DD slash YYYY Time Of Occurrence (approx) : Hours Minutes AM PM AM/PM Last Work Date MM slash DD slash YYYY Date Employer Notified MM slash DD slash YYYY Date Disability Began (If Applicable) 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 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 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) MM slash DD slash YYYY If Fatal, Give Date Of Death MM slash DD slash YYYY 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 ApplyPhysician | Healthcare Provider Name Physician | Healthcare Provider Contact Person (If Applicable) Physician | Healthcare Provider PhoneHospital | Offsite Treatment Provider PhoneHospital | Offsite Treatment Facility Name Hospital | 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 Treatment No Medical Treatment Minor: By Employer Minor: Clinic | Hospital Emergency Care Overnight Hospitalization Future Major Medical / Lost Time Anticipated Upload Any Files Drop files here or Select files Max. file size: 60 MB. 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