Indiana Workers Comp First Report Of Injury Details

Workers compensation injury report forms are an important way for employers to document workplace injuries and ensure that employees receive the appropriate medical care. The form helps employers track the dates and circumstances of injuries, as well as their workers' compensation claim status. Completing a workers compensation injury report form can be daunting, but our guide will help make it easy. In this guide, we'll explain what information is required on the form and provide tips for completing it accurately. We'll also discuss common errors made on workers compensation injury reports and how to avoid them.

This quick report can help you determine just how long it will take you to fill out workers compensation injury report, the number of pages it's got, and some additional unique details about the PDF.

QuestionAnswer
Form NameWorkers Compensation Injury Report
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesworkers compensation injury report, fillable workers compensation first report of injury, workers compensation injury form, ia illness

Form Preview Example

WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS

EMPLOYER (NAME & ADDRESS INCL ZIP)

 

CARRIER/ADMINISTRATOR CLAIM NUMBER

OSHA LOG CASE #

REPORT PURPOSE CODE

 

 

 

 

 

 

 

 

 

JURISDICTION

JURISDICTION CLAIM NUMBER

 

 

 

 

 

 

 

 

 

INSURED REPORT NUMBER

 

 

 

 

 

 

 

 

 

 

EMPLOYER’S LOCATION ADDRESS (IF DIFFERENT)

LOCATION #

 

 

 

 

 

 

INDUSTRY CODE

EMPLOYER FEIN

 

 

 

PHONE #

CARRIER/CLAIMS ADMINISTRATOR

CARRIER (NAME, ADDRESS, & PHONE #)

 

POLICY PERIOD

CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO)

 

 

 

TO

 

 

 

 

 

 

 

 

 

 

 

CHECK IF APPROPRIATE

 

 

 

 

 

SELF INSURANCE

 

 

 

 

 

 

 

 

CARRIER FEIN

POLICY/SELF-INSURED NUMBER

 

 

ADMINISTRATOR FEIN

 

 

 

 

 

 

EMPLOYEE/WAGE

NAME (LAST, FIRST, MIDDLE)

 

 

 

 

DATE OF BIRTH

SOCIAL SECURITY NUMBER

DATE HIRED

 

 

STATE OF HIRE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS (INCL ZIP)

 

 

 

 

SEX

MARITAL STATUS

OCCUPATION/JOB TITLE

 

 

 

 

 

 

 

 

UNMARRIED

 

 

 

 

 

 

 

 

 

 

M

MALE

U

EMPLOYMENT STATUS

 

 

 

 

 

 

 

 

 

 

 

SINGLE/DIVORCED

 

 

 

 

 

 

 

 

 

 

 

 

F

FEMALE

M

MARRIED

 

 

 

 

 

 

 

 

 

 

 

 

U

UNKNOWN

S

SEPARATED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHONE

 

 

 

 

# OF DEPENDENTS

K

UNKNOWN

NCCI CLASS CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RATE

 

DAY

 

MONTH

DAYS WORKED/WEEK

 

FULL PAY FOR DAY OF INJURY?

YES

 

 

NO

PER:

 

WEEK

 

OTHER:

 

 

DID SALARY CONTINUE?

 

 

YES

 

 

NO

OCCURRENCE/TREATMENT

 

TIME EMPLOYEE

 

AM

DATE OF INJURY/ILLNESS

TIME OF OCCURRENCE

 

AM

LAST WORK DATE

DATE EMPLOYER

 

DATE DISABILITY

 

 

BEGAN WORK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTIFIED

 

 

 

 

 

BEGAN

 

 

 

 

 

 

PM

 

 

 

 

( ) CANNOT BE

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DETERMINED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTACT NAME/PHONE NUMBER

 

 

 

 

 

TYPE OF INJURY/ILLNESS

 

 

 

PART OF BODY AFFECTED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DID INJURY/ILLNESS/EXPOSURE OCCUR ON EMPLOYER’S

 

 

TYPE OF INJURY/ILLNESS CODE

 

 

PART OF BODY AFFECTED CODE

 

 

PREMISES?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE

ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS

 

 

OCCURRED

 

 

 

 

 

 

 

 

 

 

 

 

EXPOSURE OCCURRED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR

WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE

 

 

ILLNESS EXPOSURE OCCURRED

 

 

 

 

 

 

 

 

OCCURRED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED

 

 

THE EMPLOYEE OR MADE THE EMPLOYEE ILL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CAUSE OF INJURY CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE RETURN(ED) TO WORK

 

IF FATAL, GIVE DATE OF DEATH

WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED?

 

 

YES

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WERE THEY USED?

 

 

 

 

 

 

YES

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS)

 

 

HOSPITAL OR OFF SITE TREATMENT (NAME & ADDRESS)

 

 

 

INITIAL TREATMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

0

 

NO MEDICAL TREATMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MINOR: BY EMPLOYER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

MINOR CLINIC/HOSP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMERGENCY CARE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOSPITALIZED > 24 HOURS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FUTURE MAJOR MEDICAL/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOST TIME ANTICIPATED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WITNESSES (NAME & PHONE #)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE ADMINISTRATOR NOTIFIED

 

DATE PREPARED

 

PREPARER’S NAME & TITLE

 

 

 

 

 

 

PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

FORM IA-1(r 1-1-02)

 

 

SEE BACK FOR IMPORTANT INFORMATION

 

 

IAIABC 2002

 

AWCC Form 1

(Employer's First Report of Injury or Illness)

Ark. Code Ann. § 11-9-529 allows employers 10 days to report injuries. Those involving either more than 7 days of lost time or indemnity payments require Form 1. Also, a Form 1 is required for all controversions including a medical-only case. Self-insured employers file Form 1 with the AWCC; other employers send it to their insurance representatives.

Employers do NOT fill in the shaded areas.

On Form 1, employers/carriers must:

1.In the Occurrence Section list the date the employer first knew of the injury. The 10 days to report begin either on the date of disability or the date the employer was notified, whichever date is later.

2.Give the name of the carrier. An insurance agency or third party administrator should be listed in the Preparer's Section. A carrier can pre-print its name and address in the Carrier Section to help clients properly report.

3.Specify the carrier Federal Employer Identification Number (FEIN) in the Carrier Section.

4.Type or print in ink. An illegible, incomplete Form 1 will be returned.

Neglect of Form 1: Late employee benefits, exposing employers to fines.

Lack of Form 1: Delays in insurance investigation.

G eneral inquiries on Form 1 can be an swe red by the A W CC Supp ort Ser vices D ivision . Questions on a specific Form 1 may be directed to the Research and Statistics Section, which processes the accident reports. (1-800-6 22-447 2 or 501 -682-393 0).

Ark. Code Ann. §11-9-10 6(a): “Any p erson or en tity who willfully an d kno wingly make s any m aterial false statement or representation, who willfully and knowingly omits or conceals any material information, or who willfully and k now ingly em ploys a ny dev ice, sche me, o r artifice for the purpose of: obtaining any benefit or paym ent; defeating or wrongfully increasing or wrongfully decreasing any claim for benefit or payment; or obtaining or avoiding workers’ compensation coverage or avoiding payment of the proper insurance premium, or who aids and abets for any of said p urposes, und er this chapter shall be guilty of a Class D felo ny. Fifty percent (50%) of any criminal fine imposed an d co llected unde r .... this section shall be paid and a llocate d in ac cord ance with

app licable law to the Death and Permanent Total Disability Trust Fund administered by the Workers’ Compensation Co mm ission.”

(Revised 1-1-2001)

EMPLOYER’S INSTRUCTIONS

DO NOT ENTER DATA IN SHADED FIELDS

DATES:

Enter all dates in MM/DD/YY format.

INDUSTRY CODE:

This is the code which represents the nature of the employer’s business, which is contained in the Standard Industrial Classification Manual or the North American Industry Classification System, published by the Federal Office of Management and Budget.

CARRIER:

The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer of the claimant.

CLAIMS ADMINISTRATOR:

Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administering the claim.

AGENT NAME & CODE NUMBER:

Enter the name of your insurance agent and his/her code number if known. This information can be found on your insurance policy.

OCCUPATION/JOB TITLE:

This is the primary occupation of the claimant at the time of the accident or exposure.

EMPLOYMENT STATUS:

 

 

 

Indicate the employee’s work status. The valid choices are:

 

Full-Time

On Strike

Unknown

Volunteer

Part-Time

Disabled

Apprenticeship Full-Time

Seasonal

Not Employed

Retired

Apprenticeship Part-Time

Piece Worker

DATE DISABILITY BEGAN:

The first day on which the claimant originally lost time from work due to the occupation injury or disease or as otherwise designated by statute.

CONTACT NAME/PHONE NUMBER:

Enter the name of the individual at the employer’s premises to be contacted for additional information.

TYPE OF INJURY/ILLNESS:

Briefly describe the nature of the injury or illness, (eg. Lacerations to the forearm).

PART OF BODY AFFECTED:

Indicate the part of body affected by the injury/illness, (eg. Right forearm, lower back).

DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED: (eg. Maintenance Department or Client’s office at 452 Monroe St., Washington, DC 26210)

If the accident or illness exposure did not occur on the employer’s premises, enter address or location. Be specific.

FORM IA-1(r 1-1-02)

IAIABC 2002

EMPLOYER’S INSTRUCTIONS – cont’d

ALL EQUIPMENT, MATERIAL OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED:

(eg. Acetylene cutting torch, metal plate)

List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or operating when the injury or illness occurred. Be specific, for example: decorator’s scaffolding, electric sander, paintbrush, and paint.

Enter “NA” for not applicable if no equipment, materials, or chemicals were being used. NOTE: The items listed do not have to be directly involved in the employee’s injury or illness.

SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED:

(eg. Cutting metal plate for flooring)

Describe the specific activity the employee was engaged in when the accident or illness exposure occurred, such as sanding ceiling woodwork in preparation for painting.

WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED: Describe the work process the employee was engaged in when the accident or illness exposure occurred, such as building maintenance. Enter “NA” for not applicable if employee was not engaged in a work process (eg. walking along a hallway).

HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL:

(Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against the hot metal.)

Describe how the injury or illness/abnormal health condition occurred. Include the sequence of events and name any objects or substance that directly injured the employee or made the employee ill. For example: Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The worker’s right wrist was broken in the fall.

DATE RETURN(ED) TO WORK:

Enter the date following to most recent disability period on which the employee returned to work.

FORM IA-1(r 1-1-02)

IAIABC 2002