Ic Form Ia 1 – Fill Out and Use This PDF

The IC IA-1 form serves as the initial documentation for reporting an injury or illness in the workplace within the context of workers' compensation. It collects exhaustive details regarding the incident, including information about the employer, the insurance carrier, the nature of the injury or illness, when and how the incident occurred, and the medical response. Recognizing the importance of this form in the workers' compensation claim process is crucial for both employers and employees to ensure timely and accurate reporting.

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Ic Form Ia 1 PDF Details

Navigating through the intricacies of worker's compensation can be daunting, especially when it involves documenting an injury or illness. At the heart of this process is the Ic Ia 1 form, a critical document designed to record the initial details concerning workplace incidents leading to injuries or illnesses. This form serves as the first report of injury or illness, requiring comprehensive information such as employer details, insurance carrier information, and specifics about the employee involved, including their job title, nature of the injury or illness, and circumstances surrounding the event. It is meticulously structured to capture data ranging from the date of injury, whether the injury occurred on the employer's premises, to specifics about the injury or illness itself, including the part of the body affected and the type of illness or injury code. Additionally, it inquires about the use of safety equipment, details of the treatment provided, and the administrative aspects of filing and notification, underlining the importance of accurate and prompt reporting. Employers and claims administrators must approach this form with diligence, as it sets the stage for the claims process, aids in the investigation, and ensures compliance with jurisdictional requirements. Importantly, the meticulous completion of this form underscores an essential aspect of workplace safety and workers' compensation procedures, facilitating a streamlined process for all parties involved. Furthermore, it’s noteworthy that the act of filing this report is not an admission of liability by the employer, nor will the contents necessarily serve as evidence in any related proceedings, providing a level of protection for the information provided. The Ic Ia 1 form is an indispensable element of the workers' compensation ecosystem, paving the way for a systematic approach to handling workplace injuries and illnesses.

Question	Answer
Form Name	Ic Form Ia 1
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	ic_1_froi first report of injury idaho illinois iowa form

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WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS

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

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

Week

Other

# Hrs Worked per Day

Did Salary Continue?

Yes

Time Employee

Date of Injury

Time

Last Work Date

Date Employer Notified

Date Disability

Began Work

or Illness

Occurred

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

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

Were they used?

Yes

Treatment	Physician/Health Care Provider (Name & Address)		Hospital (Name & Address)	3	Initial Treatment
Treatment				3	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
Other	Date Administrator Notified	Date Prepared	Preparer’s Name & Title	Preparer’s Phone Number

Filing this report is not an admission of liability. This report shall not be evidence of any fact stated herein in any proceeding in respect of the injury,

illness or death on account of which this report is made. Idaho Industrial Commission, P.O. Box 83720, Boise, ID 83720-0041IC Form IA-1 (08/2013)

Ic Form Ia 1 – Fill Out and Use This PDF

Ic Form Ia 1 PDF Details

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