Arizona - First Report of Injury - S&C

Referral Site

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Carrier

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Employee

1. Name

First Name

Middle Name (optional)

Last Name

2. Social Security Number

3. Birth Date

4. Home Address

Address Line 1

Address Line 2

City

State

ZIP Code

5. Phone

6. Sex

Male Female

7. Marital Status

Single Married Divorced Widowed

Employer

8. Employer's Name

9. Policy Number

10. Nature of Business (Manufacturing, ETC.)

11. Office Address

Address Line 1

Address Line 2

City

State

ZIP Code

12. Telephone

Accident

13. Date of Injury or Illness

14. Time of Event

15. Time Employee Began Work

16. Date Employer Notified of Injury

17. Last Day of Work After Injury

18. Date of Return to Work

19. Employee's Occupation When Injured

Job Title

20. Class Code on Payroll Report

21. Employee's Assigned Department

23. Did Injury Occur on Employer Premises

Yes No

24. Address or Location of Accident

Address Line 1

Address Line 2

City

State

ZIP Code

25. What Was the Injury or Illness (limit to 132 characters)

Tell us the part of the body that was affected and how it was affected; be more specific than "hurt," "pain," or sore." Examples: "strained back"; "chemical burn, hand"; "carpal tunnel syndrome."

26. Part of Body Injured

27. Fatal?

Yes No

28. If the Employee Died, When Did the Death Occur?

29a. Was Employee Treated in an Emergency Room?

Yes No

29b. Name of Physician or Other Health Care Professional

First Name

Last Name

29c. Health Care Professional's Address

Address Line 1

Address Line 2

City

State

ZIP Code

30a. Was Employee Hospitalized Overnight as an In-Patient?

Yes No

30b. If Hospitalized, Hospital Name

30c. Hospital Address

Address Line 1

Address Line 2

City

State

ZIP Code

31. If Validity of Claim is Doubted, State Reason

Cause of Accident

32. What Happened?

Tell us how the injury occurred. Examples: "When ladder slipped on wet floor, worker fell 20 feet"; "Worker was sprayed with chlorine when gasket broke during replacement"; "Worker developed soreness in wrist over time."

33. What Object or Substance Directly Harmed the Employee?

Examples: "concrete floor"; "chlorine"; "radial arm saw." If this question does not apply to the incident, leave it blank.

34. What was the Employee Doing Just Before the Incident Occurred?

Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. Examples: "climbing a ladder while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-entry."

35. If Another Person Not in Company Employ Caused Accident, Give Name and Address

Employee Wage Data

38. Was Employee on Overtime when Injured?

Yes No

37a. Worked From

37b. Worked Until/Through

36. Was Worker in your Employ when Injured? - Copy

Yes No

39a. Number of Days per Week Usually Worked by Employee

39b. Number of Days per Week Usually Worked at Company

Important 2

Is Employee Paid Other Than Fixed Weekly or Monthly Salary?

Yes No

If so, complete items 48-55

48. If Employee Earns Extra Pay for Overtime, What is Basis of Payment?

per hour

49. Number of Hours Overtime Considered Normal per Week

Gross Wages of Employee During 12 Months Preceeding Injury

50a. From

Beginning of the period in the prior 12 months

50b. Through

End of the period in the prior 12 months

50c. Gross Wages

During the above period

If Employee Worked Less Than 12 Months, Show Gross Wages From Date of Hire Through Day Prior to Injury

51a. From

Beginning of the period in the prior 12 months

51b. Through

End of the period in the prior 12 months

51c. Gross Wages

During the above period

52. Date of Last Wage Increase if Within 12 Months Prior to Injury

53. Wage Before Increase

54. Wage After Increase

55. Gross Earnings from Date of Increase Through Day Prior to Injury

56. Date

57. Authorized Signature

Optional

Carrier

Employee

Employer

Accident

Cause of Accident

Employee Wage Data

Important 1

Important 2