Form Am 9530 – Fill Out and Use This PDF

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

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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)

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