Form Brickstreet PDF Details

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QuestionAnswer
Form NameForm Brickstreet
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesbrickstreet report, you brickstreet, wv report injury, s you brickstreet get

Form Preview Example

BI-3

Employer’s Report of Injury

08/08

For BrickStreet Use Only

Claim Number:

Team Assigned:

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

 

1.

Name: Last

 

First

 

 

 

 

 

MI

 

6.

Date Hired:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Address:

 

 

 

 

 

 

 

 

 

7.

Telephone:

-

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

State:

 

 

 

Zip:

 

 

 

8.

Social Security Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYEE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Date of Birth:

 

 

 

4. Sex:

M

F

9.

Marital Status:

 

 

 

 

 

 

 

 

 

 

 

 

5.

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:

6.

Did Injury Occur on Employer’s Property?

Yes

No

 

 

 

 

 

 

 

 

 

Address or location where injury occurred:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

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

 

 

 

 

 

 

 

 

 

8.

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)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

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

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

Do you Have Reason to Question this Injury?

Yes

No

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

 

 

 

 

 

 

 

 

 

 

 

 

 

13.

Location of Initial Treatment:

 

 

 

Emergency Room?

Yes

No

Hospitalized?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

WAGE AND LOST TIME INFORMAITON

1. Last Day Worked After Occupational Injury or Disease:

2.

Number of Work Days Lost:

 

 

 

 

3. Date of Return to Work:

 

 

 

4. Hours Worked Per Week:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Is Light Duty Available?

Yes

No

6.

Wage on Date of Injury: $

Per

Hour

 

Day

Week

Month

 

 

 

 

 

 

7.

Are Wages Being Paid to Injured Employee

8.

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

Yes

No

During Disability?

Yes

No

 

 

 

If “yes,” indicate current wage: $

 

Per

Hour

Day

Week

Month

 

 

 

 

 

 

 

 

9.

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.

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