Erd 991 Form PDF Details

Tracking and reporting workplace injuries and occupational diseases is a critical aspect of occupational safety and health management. The Erd 991 form serves as a comprehensive tool for this purpose, used predominantly within the Montana Department of Labor and Industry. This document meticulously records vital information about the injured worker, including personal details, employment background, educational level, and dependency status, to facilitate a thorough understanding of the case at hand. It captures the date of injury or onset of occupational disease, alongside specifics of the incident, such as the job title, accident description, cause, and nature of the injury or disease. Crucial employment data like wages, employment status, and dates pertinent to the injury and recovery process are also included to assess the financial impact. The form mandates the inclusion of medical treatment details, attending physician's information, and any medical services received post-incident. This level of detail extends to the employer's section, demanding insights into the business’s nature, workers’ compensation insurance details, and the employer's assessment of the incident. By signing the form, the injured worker or beneficiary authorizes the release of relevant records for workers’ compensation purposes, acknowledging the potential legal repercussions of falsely claiming benefits. Employers and insurers are likewise required to verify the accuracy of the provided information, ensuring a mutual commitment to transparency and accountability in managing workplace injuries and diseases.

QuestionAnswer
Form NameErd 991 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesFEIN, insurer, insurers, montana state fund first report

Form Preview Example

OSHA Log Case #

First Report

Adjuster Date Stamp

of Injury or Occupational Disease

Montana Department of Labor and Industry PO Box 8011 Helena, MT 59604-8011

Worker

LAST NAME

HOME ADDRESS

FIRST NAME

M.I.

DATE OF BIRTH

 

 

CITY

 

 

 

SOCIAL SECURITY NUMBER

STATE

POSTAL CODE

 

 

PHONE NUMBER

EDUCATION

LESS THAN HIGH SCHOOL

GED OR HIGH SCHOOL DIPLOMA

BEYOND HIGH SCHOOL

GENDER

MALE

UNKNOWN

FEMALE

MARITAL STATUS

MARRIED SEPARATED

WIDOWED, DIVORCED, SINGLE, UNMARRIED

UNKNOWN

NUMBER OF DEPENDANTS

Wages

 

DATE HIRED

 

GROSS EARNINGS FOR FOUR PAY PERIODS PRECEDING THE INJURY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE/AMOUNT

/

 

 

 

DATE/AMOUNT

 

/

 

 

 

DATE/AMOUNT

/

 

 

 

DATE/AMOUNT

/

 

 

 

EMPLOYMENT STATUS

 

 

 

 

 

 

 

 

 

 

 

NUMBER OF DAYS WORKED PER WEEK

WAGE

 

 

 

WAGE PERIOD

 

 

 

 

 

 

 

FULL TIME

PART TIME

SEASONAL

PIECE WORKER

 

 

 

 

 

 

 

 

 

 

 

 

 

HOUR

 

WEEK

 

 

MONTH

OTHER

 

VOLUNTEER

OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DAY

 

BI-WEEKLY

YEAR

 

 

IN ADDITION TO GROSS EARNINGS CITED ABOVE WORKER RECEIVED

 

 

 

 

ESTIMATED VALUE IF ANY

 

 

 

 

TIME EMPLOYEE BEGAN WORK

 

 

ROOM & BOARD

OVERTIME

 

 

 

BONUS

 

COMMISSIONS

OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WORKED NEXT SCHEDULED SHIFT

 

 

OFF WORK MORE THAN 4 WORK DAYS

 

DATE LAST WORKED

 

DATE OF RETURN TO WORK

 

FULL WAGES PAID FOR

 

 

SALARY CONTINUED

 

YES

NO

 

 

 

 

 

YES

 

NO

NOT SURE

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF INJURY

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accident Description

 

 

 

 

 

 

 

 

 

 

 

 

JOB TITLE

 

DESCRIPTION OF ACCIDENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CAUSE OF INJURY

 

 

 

 

 

 

 

CAUSE CODE

 

 

PART OF BODY

 

 

 

PART CODE

NATURE OF INJURY

 

NATURE CODE

 

DATE OF INJURY

TIME OF INJURY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE DISABILITY BEGAN

 

 

 

 

 

 

DATE OF DEATH

 

 

 

 

NAMES OF WITNESSES

 

 

2)

 

 

 

 

 

3)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACCIDENT ON EMPLOYER’S PREMISES

 

 

 

ACCIDENT ADDRESS OR LOCATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

CITY

 

 

 

 

STATE

 

 

 

 

POSTAL CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE EMPLOYER NOTIFIED

 

 

 

 

 

 

ACCIDENT REPORTED TO

 

 

 

 

 

 

 

 

 

 

 

SAFETY EQUIPMENT PROVIDED

 

 

SAFETY EQUIPMENT USED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical

ATTENDING PHYSICIAN’S NAME

ADDRESS

 

STATE

POSTAL CODE

 

PHONE NUMBER

 

 

 

 

 

 

PHONE NUMBER

HOSPITAL NAME

ADDRESS

 

STATE

POSTAL CODE

 

 

 

 

 

 

 

-SITE BY EMPLOYER OR MEDICAL STAFF

TYPE OF INITIAL MEDICAL TREATMENT

RECEIVED

NO TREATMENT

EMERGENCY ROOM/U

RGENT CARE

TREATMENT ON

HOSPITAL>24 HOURS

 

 

 

 

 

 

CLINIC/DR. OFFICE

Signature

“This is my claim for workers’ compensation benefits due to the on-the-job injury, occupational disease or death of the above named worker. I understand that signing this claim for compensation authorizes the release to the workers’ compensation insurer or its agent, rehabilitation records, Social Security records and health care information (medical records, pursuant to HIPAA, Public Law 104-191, 42 USC section 1301, et. seq., and section 39-71-604, MCA) that are directly relevant to the claimed injury, disease or death. I also understand that if I obtain or exert unauthorized control over workers’ compensation benefits to which I am not entitled, I may be prosecuted for theft.”

Signature of Injured Worker or Beneficiary

Date

Employer

EMPLOYER NAME

DOING BUSINESS AS

FEDERAL EMPLOYER IDENTIFICATION NUMBER (TAX ID)

MAILING ADDRESS

 

CITY

 

STATE

 

 

 

POSTAL CODE

 

PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION OF OPERATION, IF DIFFERENT FROM MAILING ADDRESS

 

 

 

NATURE OF BUSINESS

 

SELF-INSURED?

YES

NO

 

 

 

 

 

 

 

SIC/NAICS CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIMITED LIABILITY COMPANY

EMPLOYER IS A

SOLE PROPRIETORSHIP

PARTNERSHIP

INJURED WORKER IS A

SOLE P

ROPRIETORSHIP

PARTNERSHIP

CORPORATION

CORPORATION

LIMITED LIABILITY COMPANY

A MEMBER OF THE EMPLOYER’S (SOLE PROPRIETOR OR PARTNER) FAMILY LIVING IN THE EMPLOYER’S HOUSEHOLD

 

 

 

 

 

 

 

 

 

WAS WORKER INJURED WHILE IN YOUR EMPLOY

DO YOU HAVE ANY REASON TO QUESTION THIS ACCIDENT?

 

YES

NO

 

 

IF YES, PLEASE EXPLAIN FULLY. USE SEPARATE SHEET IF YOU NEED ADDITIONAL SPACE

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prepared By

 

 

 

Official Title

 

 

 

Phone Number

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAYROLL CLASSIFICATION CODE UNDER WHICH YOU

 

 

 

 

 

 

 

 

 

 

 

 

 

REPORT EMPLOYEE’S WAGES

 

AUTHORIZED EMPLOYER’S SIGNATURE_______________________________________________

DATE__________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurer

CLAIM ADMINISTRATOR CLAIM NUMBER

DATE REPORTED TO CLAIM ADMINISTRATOR

THE ABOVE INFORMATION IS CORRECT WITH THE FOLLOWING EXCEPTIONS (ATTACH EXTRA SHEETS IF BOX AT RIGHT IS CHECKED)

CLAIM ADMINISTRATOR’S NAME

CLAIM ADMINISTRATOR ADDRESS

 

CLAIM ADMINISTRATOR FEIN

 

 

 

 

 

 

 

INSURER NAME

 

INSURER FEIN

 

 

 

 

 

 

 

 

 

POLICY NUMBER

 

POLICY EFFECTIVE DATE

 

POLICY EXPIRATION DATE

 

 

 

 

 

 

 

ERD – 991 (Rev. 04/09 ER)

How to Edit Erd 991 Form Online for Free

Our PDF editor makes it easy to prepare the ERD document. It will be easy to obtain the document effortlessly by simply following these simple steps.

Step 1: Choose the "Get Form Here" button.

Step 2: Now you can change your ERD. You may use the multifunctional toolbar to add, delete, and modify the content of the file.

All of these areas are contained in the PDF document you will be filling out.

montana state fund forms empty fields to consider

Type in the essential information in the field HOSPITAL NAME, ADDRESS, STATE, POSTAL CODE, PHONE NUMBER, TYPE OF INITIAL MEDICAL TREATMENT, NO TREATMENT, EMERGENCY ROOMURGENT CARE, TREATMENT ONSITE BY EMPLOYER OR, CLINICDR OFFICE, HOSPITAL HOURS, Signature This is my claim for, EMPLOYER NAME, DOING BUSINESS AS, and FEDERAL EMPLOYER IDENTIFICATION.

Filling out montana state fund forms step 2

Note down all particulars you are required in the space INSURER NAME, POLICY NUMBER, ERD Rev ER, INSURER FEIN, POLICY EFFECTIVE DATE, and POLICY EXPIRATION DATE.

step 3 to completing montana state fund forms

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