BMI - First Report of Injury - NJ - Formstack

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Workers Compensation - First Report of Injury or Illness

1 EMPLOYER NAME

2 EMPLOYER ADDRESS INCL ZIP

Address Line 1

Address Line 2

City

State

ZIP Code

3 INDUSTRY CODE

4 EMPLOYER FEIN

5 CARRIER / ADMINISTRATOR CLAIM NUMBER

6 OSHA LOG NUMBER

7 REPORT PURPOSE CODE

8 JURISDICTION

9 JURISDICTION CLAIM NUMBER

10 INSURED REPORT NUMBER

11 EMPLOYERS LOCATION ADDRESS IF DIFFERENT

Address Line 1

Address Line 2

City

State

ZIP Code

12 LOCATION #

13 PHONE #

14 CARRIER / CLAIMS ADMIN NAME

15 CARRIER / CLAIMS ADMIN ADDRESS

Address Line 1

Address Line 2

City

State

ZIP Code

16 CARRIER / CLAIMS ADMIN PHONE #

17 POLICY PERIOD FROM

18 POLICY PERIOD TO

19 CHECK IF APPROPRIATE (SELF INSURANCE)

Yes

20 POLICY / SELF-INSURED NUMBER

21 ADMINISTRATOR FEIN

22a EMPLOYEE LAST NAME

22b EMPLOYEE FIRST NAME

22c EMPLOYEE MIDDLE NAME

23 EMPLOYEE ADDRESS

Address Line 1

Address Line 2

City

State

ZIP Code

24 EMPLOYEE PHONE NUMBER

25 EMPLOYEE DATE OF BIRTH

26 EMPLOYEE SOCIAL SECURITY NUMBER

27 SEX

Male Female Unknown

28 MARITAL STATUS

Unmarried, single/divorced Married Separated Unknown

29 # OF DEPENDENTS

30 DATE HIRED

31 STATE OF HIRE

32 OCCUPATION / JOB TITLE

33 EMPLOYMENT STATUS

34a RATE

34b RATE PER:

Day Week Month Other

34c IF OTHER

35 DAYS WORKED / WEEK

36 FULL PAY FOR DAY OF INJURY?

Yes No

37 DID SALARY CONTINUE?

Yes No

38 TIME EMPLOYEE BEGAN WORK

:

39 DATE OF INJURY / ILLNESS

40a TIME OF OCCURRENCE

:

40b TIME OF OCCURRENCE - CANNOT BE DETERMINED (OPTIONAL)

Yes

41 LAST WORK DATE

42 DATE EMPLOYER NOTIFIED

43 DATE DISABILITY BEGAN

44 CONTACT NAME

45 CONTACT PHONE NUMBER

46 TYPE OF INJURY / ILLNESS

47 PART OF BODY AFFECTED

48 DID INJURY / ILLNESS / EXPOSURE OCCUR ON EMPLOYER'S PREMISES?

Yes No

49 DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

50 ALL EQUIPMENT MATERIALS OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

51 SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

52 WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

53 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.

54 DATE RETURNED TO WORK

55 IF FATAL GIVE DATE OF DEATH

56 WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED?

Yes No

57 WERE THEY USED?

Yes No

58 PHYSICIAN HEALTH CARE PROVIDER NAME

59 PHYSICIAN HEALTH CARE PROVIDER ADDRESS

Address Line 1

Address Line 2

City

State

ZIP Code

60 HOSPITAL OR OFF SITE TREATMENT NAME

61 HOSPITAL OR OFF SITE TREATMENT ADDRESS

Address Line 1

Address Line 2

City

State

ZIP Code

62 INITIAL TREATMENT

No medical treatment Minor: By Employer Minor Clinic / Hospital Emergency Care Hospitalized > 24 Hours Future Major Medical / Lost Time Anticipated

63 WITNESS NAME

64 WITNESS ADDRESS

Address Line 1

Address Line 2

City

State

ZIP Code

65 DATE ADMINISTRATOR NOTIFIED

66 DATE PREPARED

67 PREPARERS NAME AND TITLE

68 PHONE NUMBER

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