Form Brickstreet – Fill Out and Use This PDF

The Brickstreet form, officially known as BI-3 Employer’s Report of Injury, is a critical document for reporting workplace injuries or diseases to BrickStreet Mutual Insurance. It requires detailed information about the employer, the employee, the incident, and any lost wages due to the injury. For employers, filling out this form accurately and timely is essential to ensure compliance with West Virginia Code § 61-3-24e and to facilitate the injured employee's claim process. Ensure you complete the form by clicking the button below.

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Form Brickstreet PDF Details

The Brickstreet BI-3 Employer’s Report of Injury form serves as a critical document in the reporting and management of workplace injuries. Developed to streamline the process of notifying insurance carriers about incidents, it encapsulates several crucial aspects including employer and employee information, details about the injury or disease, wage and lost time data, and specific instructions for completion and submission. Employers are required to provide comprehensive details such as the insurance policy number, nature of the business, and an array of employee specifics like their job title and the nature of their employment. The form delves into the intricacies of the injury or disease, requesting information on when and how the incident occurred, the type of injury, where the initial treatment was administered, and if the injury was potentially fatal. Additionally, it covers wage information before and after the injury, shedding light on any lost workdays and if the employee is receiving wages during their disability period. This meticulous documentation is not only pivotal for the insurance process but is mandated by law, with strict penalties in place for any false reporting. Completing the BI-3 form accurately is essential, not just for compliance but to ensure the injured employee receives the support and benefits they are entitled to, reflecting the form’s significance in fostering a responsible and responsive workplace injury management system.

Question	Answer
Form Name	Form Brickstreet
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	brickstreet report, you brickstreet, wv report injury, s you brickstreet get

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BI-3

Employer’s Report of Injury

08/08

For BrickStreet Use Only

Claim Number:

Team Assigned:

EMPLOYER	INFORMATION
EMPLOYER	INFORMATION

1.BrickStreet Insurance Policy Number:

4.Employer’s Name:

5.Address:

City:

2. FEIN or SSN:	3. Nature of Business:

State:	Zip:	6. Telephone:	-	-

INFORMATION

Name: Last

First

Date Hired:

Address:

Telephone:

City:

State:

Zip:

Social Security Number:

EMPLOYEE

Date of Birth:

4. Sex:

Marital Status:

Injured Employee is: (check all that apply)

Full-Time

Part-Time

Volunteer

10. Employee’s Occupation / Job Title:

Owner / Partner

Officer

Retired – Date Retired:

INFORMATION ABOUT INJURY / DISEASE

1. Date of Injury or Last Exposure:

Time:

a.m.

p.m.

5. Witnesses to Injury:

2.Date Employer Notified of Injury or Disease:

3.Supervisor to Whom Injury or Disease Reported:

4.If Injury was Fatal, Indicate Date of Death:

Did Injury Occur on Employer’s Property?

Yes

Address or location where injury occurred:

What was the Employee Doing When Injury Occurred? (loading truck, walking down stairs, etc.)

How did the Injury or Disease Occur? (Be specific, include time that employee began work on date of injury, any equipment, tools substances or objects connected to

the injury; attach additional sheet(s) if necessary)

Nature of Injury or Disease (cut, bruise, strain, etc.)

10.

Body Part(s) Injured:

11.

Are you Aware of, or Do You Suspect, a Prior Injury to this Body Part?

Yes

12.

Do you Have Reason to Question this Injury?

Yes

(If “yes,” attach a specific explanation to this form.)

13.

Location of Initial Treatment:

Emergency Room?

Yes

Hospitalized?

Yes

WAGE AND LOST TIME INFORMAITON

1. Last Day Worked After Occupational Injury or Disease:

Number of Work Days Lost:

3. Date of Return to Work:

4. Hours Worked Per Week:

Is Light Duty Available?

Yes

Wage on Date of Injury: $

Per

Hour

Day

Week

Month

Are Wages Being Paid to Injured Employee

If Employee Has Returned to Work, is it Alternative or Modified Work?

Yes

During Disability?

Yes

If “yes,” indicate current wage: $

Per

Hour

Day

Week

Month

Daily Rate of Pay on Date of Injury: $

and best quarter wages of preceding four quarters: $

I certify the statements and answers set forth in this section are true and correct to the best of my knowledge. I am aware the law, specifically West Virginia Code § 61-3-24e provides for severe penalties if I knowingly certify a false report or statement and / or withhold a material fact regarding any information requested. I acknowledge the provisions of the aforementioned code and the severe penalties for knowingly with fraudulent intent aiding or abetting anyone in securing or attempting to secure benefits to which he or she is not entitled.

Print Name:

Title:

Signature:

Date:

BrickStreet Mutual Insurance  P.O. Box 3151  Charleston, WV  25332

General instructions for completing the

BI-3, “Employer’s Report of Injury”

Please Read Carefully

To the Employer: W.V. Code 23-4-1b requires you to report the injury to your carrier within five days of receipt of notification from an employee’s injury.

This form should not be used to file occupational pneumoconiosis or hearing loss claims.

To report a claim, please contact BrickStreet at 1-866-452-7425. If completing this form, make a copy for your records.

Return completed form to:	BrickStreet Mutual Insurance
	P. O. Box 3151
	Charleston, WV 25332-3151

When completing this form, please attach additional pages if space is needed. Also attach any witness statements and reports you wish to submit.

Form Brickstreet – Fill Out and Use This PDF

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