Form Am 9530 PDF Details

In the realm of occupational safety and tribal employment, the AM 9530 form stands as a crucial document intended for meticulously reporting workplace injuries within tribal entities. Crafted specifically for members of the AMERIND Tribal Employee Injury Protection Risk Pool, this form represents an essential procedure for employers to promptly communicate the occurrence of an employee injury to the Berkley Risk Administrators Company, LLC. The detailed sections within this form encompass various key aspects such as employer and employee information, an encompassing description of the accident including the time, location, and nature of the injury, as well as the attending physician's details. Additionally, it solicits comprehensive data regarding the employee's wage, vital for calculating potential benefits. Timeliness is underscored, with employers mandated to submit this report within a mere 24 hours after being notified of the incident, emphasizing the form’s role in facilitating swift action and response to workplace accidents. Despite its detailed nature, it is noteworthy that completing and submitting the AM 9530 form does not automatically guarantee the payment of benefits, indicating the initial step in a possibly extensive claim review process.

QuestionAnswer
Form NameForm Am 9530
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names2010, Waqes, throuqh, Iniured

Form Preview Example

AMERIND TRIBAL EMPLOYEE INJURY PROTECTION RISK POOL

EMPLOYEE INJURY REPORT

TO BE FILLED OUT BY EMPLOYER

Submit Report to:

CLAIM ADMINISTRATOR

 

 

 

 

 

 

 

 

 

Complete and return this report to the

 

BERKLEY RISK ADMINISTRATORS COMPANY, LLC

address shown at left within 24 hours

 

PO BOX 59143

 

 

 

 

 

 

 

 

 

 

 

 

of notice of injury.

 

MINNEAPOLIS, MN 55459-0143

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tel. (866) 448-1761

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax (612) 766-3099

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER INFORMATION

 

 

 

 

 

 

 

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I Policy Period

 

 

 

"

 

 

 

 

 

 

 

 

"

 

Policy Number

 

 

Nature of Business (Tribal Government, Casino, Etc)

 

4444-00002

 

 

3/13/2010

to 3/13/2011

 

 

FED. RECOGNIZED TRIBE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Person

 

Affiliate Name and Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SHOSHONE-PAIUTE TRIBES OF THE DUCK VALLEY INDIAN RESERVATION

 

 

 

 

 

 

 

 

PO BOX 219

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Phone No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OWYHEE NV 89832

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Fax No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title of Person Completing Form

 

ISignature of Person

 

Completing Fonn I Date Completed

 

Name of Person Completing Report

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYEE INFORMATION

 

-- ｾ ..ＭＭｾＧ

--

-

-

_..

..

- .

ｾＭＭＭＬｾ - -- .

--

 

 

 

._ ..

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

First

 

 

 

M.1.

ISocial

Security Number

 

ISex

Birth Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Address (Number & Street)

 

 

 

 

 

City

 

 

 

 

 

 

State

Zip Code

Phone No.

 

 

 

 

 

 

 

 

I Employee's Assigned Department

 

 

 

 

 

Employee's Job Title When Injured

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIPTION OF ACCIDENT

 

 

 

 

 

 

.... ,

,

 

 

 

, - ,

 

 

 

 

 

 

 

 

 

 

Date of Injury

 

ITime of Injury

 

I Last Day of Work After

I Date of Return to Work

Date Employer Notified of

 

 

 

 

 

 

 

Injury

 

 

 

 

 

 

 

 

 

 

 

 

 

Injury

Address or Location of Accident

 

 

 

 

 

City

 

 

 

 

 

 

State

Zip Code

On Employer Premises?

 

 

(Scratch, Cut, Etc.)

 

 

 

 

 

 

 

 

 

 

 

Was Injury Fatal?

I Nature of Injury

 

 

 

 

 

 

 

 

 

Part of Body Injured

 

 

 

 

 

Emergency Room, Hospital or Medical Facility Treated by (Name, Address & Phone)

 

Attending Physician (Name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How Did Accident Happen? What Was Employee Doing When Accident Occurred? (State All Details, Use Other Side if Needed)

If Validity of Claim Is Doubted, State Reason

EMPLOYEE'S WAGE DATA

 

 

 

 

 

 

 

 

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was Worker in

 

Date of Last Hire

Hours Per

From

 

Number of

 

Employee

Your Employ

 

 

 

 

Day Employee

 

Days Per

 

Usually

 

 

 

 

To

 

 

When Iniured

 

 

 

 

Worked

 

Week:

 

Works

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

o Month

 

 

Employee's Wage $

 

Per o Hour o Day o Week

 

 

 

 

 

 

Gross Wages of Employee During 26 Weeks Preceding

 

 

Personal Time Off during

 

From

 

the 26 calendar weeks

 

Injury; or if Employee Worked Less Than 26 Weeks, Gross

$

 

To

precedinq injury.

 

Waqes From Date of Hire throuqh Day Prior to Injury

 

 

 

 

 

This form does not guarantee payment of benefits

AM 9530 (9/05)

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