Indiana State Form 34401 – Fill Out and Use

EMPLOYEE INFORMATION

Social Security Number

Date of Birth

Sex

Occupation / Job Title

NCCI class code

MALE

FEMALE

UNKNOWN

N/A

Name (last, first, middle)

Marital status

Date hired

State of hire

Employee status

UNMARRIED

N/A

N/A

MARRIED

Address (number and street, city, state, ZIP code)

Hrs / Day

Days / Wk

Avg Wg / Wk

Paid Day of Injury

SEPARATED

Salary Continued

UNKNOWN

Wage

Per

Telephone number (include area code)

Number of dependents

Hour

Day

Week

Month

N/A

Year

Other

Name of claims administrator

Carrier federal ID number

Check if appropriate

N/A

N/A

N/A

SELF INSURANCE

Address of claims administrator(number and street, city, state, ZIP code) N/A

Policy / Self-insured number

N/A

Insurance Carrier N/A

Third PArty Admin. N/A

Policy period

Telephone number

N/A

N/A

TO N/A

FROM

Name of agent

N/A

Code number

N/A

OCCURRENCE / TREATMENT INFORMATION

Date of Inj. / Exp.

Time of occurrence

Date employer notified

Type of injury / exposure

Type code

AM

PM

N/A

Last work date

Time workday began

Date disability began

Part of body

Part code

N/A

RTW date

Date of death

Injury / Exposure occurred

YES

Name of contact N/A

Telephone number

N/A

on employer's premises?

NO

Department or location where accident / exposure occurred

All equipment, materials, or chemicals

N/A

NA

Specific activity engaged in during accident / exposure

Work process employee engaged in during accident / exposure

N/A

NA