First Report of Claim

Insured
Name:
Address:
City: State: Zip Code:
County:
Phone: Fax:
E-mail:
FEIN: NAICS Code:
Policy
Number:
Agent:
Policy Period From Date: Policy Period To Date:
Employee Information
Name:
Address:
City: State: Zip Code:
County:
Phone: Fax:
E-mail: SSN:
Gender: Male Female Marital Status: Married Single
Date of Birth: Number of Dependents:
Date of Injury:
Occupation or Job Title:
Witness Information
Name:
Phone:
Accident Information
Full Pay for Day of Injury: Yes No
Time Employee Began Work: AM PM
Time of Occurrence: AM PM
Date of Hire: Last Day Worked:
Date Disability Began:
Date Employer Notified:
Date Returned to Work:
Contact Name:
Contact Phone:
Type of Injury Code: Part of Body Affected Code:
Cause of Injury Code:
Type of Injury or Illness:
Parts of Body Affected:
Cause of Injury:
Did Injury or Illness Occur on Employer's Premises?: Yes No
If Out of State, Specify State of Injury:
Were Safeguards or Safety Equipment Provided?: Yes No
Were Safeguards or Safety Equipment Used?: Yes No
Treatment Information
If Fatal, Give Date of Death:
Physician/Health Care Provider
Name:
Address:
City: State: Zip Code:
 
Hospital Name:
City: State: Zip Code:
Initial Treatment:
No Medical Treatment Minor by Employee
Clinic\Hospital Panel Physician
Employee Physician Emergency Care
Hospitalized More Than 24 Hours