Ic Form Ia 1 – Fill Out and Use This PDF

Employer (Name & Address incl. zip)

Carrier/Administrator Claim Number

Report Purpose Code

Jurisdiction

Jurisdiction Claim No.

General

Insured Report No.

Employer’s Location Address (if different)

Location No.

NAICS Code

Employer FEIN

Phone No.

Carrier (Name, Address & Phone Number)

Policy Period

Claims Admin (Name, Address & Phone Number)

Admin

To

Carrier/Claims

Agent Name & Code Number

Check if

self

insured

Carrier FEIN

Policy Number or Self-Insured Number

Administrator FEIN

Legal Name (Last, First, Middle)

Birth Date

Social Security Number

Date Hired

State of Hire

Address (Incl. Zip)

Sex

Marital Status

Occupation/Job Title

Male

Unmarried/

Employee

Single/Div.

Female

Married

Employment Status

Unknown

Separated

Phone

No. of Dependents

Unknown

NCCI Class Code

Wage Rate

Day

Month

# Days Worked/WK

Full Pay for Date of Injury?

Yes

No

$

Week

Other

# Hrs Worked per Day

Did Salary Continue?

Yes

No

Time Employee

AM

Date of Injury

Time

AM

Last Work Date

Date Employer Notified

Date Disability

Began Work

PM

or Illness

Occurred

PM

Began

Employer Contact Name/Phone Number

Type of Illness/Injury

Part of Body Affected

Did Injury/Illness Exposure Occur on Employer’s

Yes

TypeofIllness/InjuryCode

Part of Body Affected Code

Premises?

Occurrence

No

Department or location where accident or illness exposure occurred

All Equipment, Materials, or Chemicals Employee Using upon Occurrence

Specific Activity Employee Engaged in at Time of Occurrence

Work Process the Employee Was Engaged in at Time of Occurrence

How injury or illness/abnormal health condition occurred. Describe the sequence of events and include any objects or substances

Cause of Injury

that directly injured the employee or made the employee ill.

Code

Date Returned to Work

If Fatal, Date of Death

Were Safeguards or Safety Equipment Provided?

Yes

No

Were they used?

Yes

No

Treatment

Physician/Health Care Provider (Name & Address)

Hospital (Name & Address)

3

Initial Treatment

Emergency Care

0

No Medical Treatment

1

Minor: By Employer

2

Minor Clinic/Hosp

4

Hospitalized – 24 hr.

Signature of Injured Employee, or Signature on File,

Witness to Accident (Name & Phone Number)

5

Anticipated Major Med/Lost

Other

Date

Time

Date Administrator Notified

Date Prepared

Preparer’s Name & Title

Preparer’s Phone Number