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Employer
Employer (Name)
Employer (Address)
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Employer FEIN
Employer's Location Address (If Different)
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Location Number
Phone Number
Carrier (Claims admin)
Please Choose Your Carrier
American Liberty Insurance Company
AmTrust Insurance Co of Kansas, Inc.
Benchmark Insurance Company
Utah Business Insurance Company
Check if appropriate
Self-Insured
Agent Name
Employee
Name
First Name
Middle Name (optional)
Last Name
Employee Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Date of Birth
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Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Social Security Number
Date Hired
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Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
State of Hire
Employee phone
Number of Dependents
Claimant may need an interpreter?
Yes
No
Sex
Male
Female
Unknown
Marital Status
Unmarried/Single/Divorced
Separated
Married
Unknown
Occupation/job title
Employment Status
NCCI Class Code
Wage
Rate
Rate per
Day
Week
Month
Other
Number of days worked/week
Full Pay for Date of Injury?
Yes
No
Did Salary Continue?
Yes
No
Occurence
Occurrence/Treatment
Time Employee Began Work
Hour
01
02
03
04
05
06
07
08
09
10
11
12
Minute
:
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM/PM
AM
PM
Date of Injury/Illness
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Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Time of Occurrence
Hour
01
02
03
04
05
06
07
08
09
10
11
12
Minute
:
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM/PM
AM
PM
Last Work Date
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Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Date Employer Notified
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Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Date Disability Began
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Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Contact Name
First Name
Last Name
Contact Phone
Type of Illness/Injury
Part of Body Affected
Did Injury/Illness Exposure Occur on Employer’s Premises?
Yes
No
Department or location where accident or illness exposure occurred
All equipment, materials, or chemicals employee was using when accident or illness exposure occurred
Specific activity the employee was engaged in when the accident or illness exposure occurred
Work process the employee was engaged in when accident or illness exposure occurred
How injury or illness/abnormal health condition occurred, describe the sequence of events and include objects or substances that directly injured the employee or made the employee ill
Date Returned to Work
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Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
If Fatal, Date of Death
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Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Were Safeguards or Safety Equipment Provided?
Yes
No
Were they used?
Yes
No
Physician/health care provider name
Physician/health care provider address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Hospital Name
Hospital Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Initial Treatment
No Medical Treatment
Minor: Clinic/Hospital
Hospitalized - 24 hrs
Minor: By Employer
Emergency Care
Future Major Medical/Lost Time Anticipated
Other
Witnesses (names and phone numbers)
Date Administrator Notified
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Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Date Prepared
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Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Name
*
First Name
*
Last Name
*
Preparer's Title
*
Phone number
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