Idaho - First Report - S&C

Referral Site

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General

Employer's Name

Employer's Address

Address Line 1

Address Line 2

City

State

ZIP Code

NAICS Code

Employer FEIN

Carrier/Administrator Claim Number

Report Purpose Code

Jurisdiction

Jurisdiction Claim No.

Insured Report No.

Employer’s Location Address (if different)

Address Line 1

Address Line 2

City

State

ZIP Code

Location No.

Phone No.

Carrier/Claims Admin

Please choose your Carrier

Policy Period From

Policy Period To

Check if Self-Insured

Self-Insured

Policy Number or Self-Insured Number

Claims Admin Name

Claims Admin Phone Number

Claims Admin Address

Address Line 1

Address Line 2

City

State

ZIP Code

Agent Name

Agent Code Number

Occurence

Time Employee Began Work

Date of Injury or Illness

Time Occurred

Last Work Date

Date Employer Notified

Date Disability Began

Employer Contact Name

Employer Phone Number

Did Injury/Illness Exposure Occur on Employer’s Premises?

Yes No

Type of Illness/Injury

Part of Body Affected

Type of Illness/Injury Code

Part of Body Affected Code

Department or location where accident or illness exposure occurred

All Equipment, Materials, or Chemicals Employee Using upon Occurrence

Specific Activity Employee Engaged in at Time of Occurrence

Work Process the Employee Was Engaged in at Time of Occurrence

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.

Cause of Injury Code

Date Returned to Work

If Fatal, Date of Death

Were Safeguards or Safety Equipment Provided?

Yes No

Were they used?

Yes No

Treatment

Treatment Physician/Health Care Provider Name

Treatment Physician/Health Care Provider Address

Address Line 1

Address Line 2

City

State

ZIP Code

Hospital Name

Hospital Address

Address Line 1

Address Line 2

City

State

ZIP Code

Initial Treatment

No Medical Treatment Minor Clinic/Hosp Hospitalized - 24 hr. Minor: By Employer Emergency Care Anticipated Major Med/Lost Time

Other

Witness to Accident Name

Witness to Accident Phone

Date Administrator Notified

Date Prepared

Preparer's Name

Preparer's Title

Preparer's Phone Number