BMI - First Report of Injury - OK - Formstack

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1 Full Name Of Employee

First Name

Middle Name (optional)

Last Name

2 Employee Email Address

3 Complete Address

Address Line 1

Address Line 2

City

State

ZIP Code

4 Telephone Number

5 Employee's Social Security Number (last 5 Digits Only)

6 Date Of Birth

7 Sex

8 Length Of Employment (years)

9 Length Of Employment (months)

10 Length Of Employment (date Of Hire)

11 Average Weekly Wage

12 Occupation (job Description)

13 Was Employment Agreement Made In Oklahoma?

Yes No

14 Date Of Accident Or Last Exposure

15 Time Of Accident Or Exposure

:

16 Date Employer Notified

17 Time Workday Began

:

18 Last Date Employee Worked

19a Has Employee Returned To Work?

Yes No

19b If Yes, On What Date?

20a Did The Employee Die?

Yes No

20b If Yes, On What Date?

21 OSHA Log Case Numbrer

22a Place Of Accident Or Occurance (city)

22b Place Of Accident Or Occurance (county)

22c Place Of Accident Or Occurance (state)

23 Injury Resulted From:

Single Incident Cumulative Trauma Occupational Disease

24 Nature Of Injury Or Illness

25a Does Employee Participate In A Certified Workplace Medical Plan:

Yes No

25b If Yes, Name Of CWMP

26 Describe activities when injury occurred with details of how event occurred. Include object or substance which directly injured the employee.

27 Identify Part(s) Of Body Involved In Injury Or Illness

28 Full Name And Address Of Treating Physician (please Be Complete)

29 Employer's Insurance Carrier Or Own Risk Group (name)

30 Employer's Insurance Carrier Or Own Risk Group (phone)

31 Employer's Insurance Carrier Or Own Risk Group (address)

Address Line 1

Address Line 2

City

State

ZIP Code

32 Policy/Self-Insured Number

33 Policy Period (from)

34 Policy Period (to)

35 Employer's Name

36 Employer's Address

Address Line 1

Address Line 2

City

State

ZIP Code

37 Federal ID#

38 Phone #

39 Type Of Business

40 NAICS Number

41 Type Of Ownership

Private State Government County Government Local Government

42 Singnature Of Preparer

43 Name And Title Of Preparer

44 Telephone (area Code And Number)

45 Date

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