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.
Question | Answer |
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Form Name | Workers Compensation Injury Report |
Form Length | 4 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min |
Other names | workers compensation injury report, fillable workers compensation first report of injury, workers compensation injury form, ia illness |
WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS
EMPLOYER (NAME & ADDRESS INCL ZIP) |
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CARRIER/ADMINISTRATOR CLAIM NUMBER |
OSHA LOG CASE # |
REPORT PURPOSE CODE |
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JURISDICTION |
JURISDICTION CLAIM NUMBER |
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INSURED REPORT NUMBER |
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EMPLOYER’S LOCATION ADDRESS (IF DIFFERENT) |
LOCATION # |
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INDUSTRY CODE |
EMPLOYER FEIN |
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PHONE # |
CARRIER/CLAIMS ADMINISTRATOR
CARRIER (NAME, ADDRESS, & PHONE #) |
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POLICY PERIOD |
CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO) |
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TO |
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CHECK IF APPROPRIATE |
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SELF INSURANCE |
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CARRIER FEIN |
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ADMINISTRATOR FEIN |
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EMPLOYEE/WAGE
NAME (LAST, FIRST, MIDDLE) |
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DATE OF BIRTH |
SOCIAL SECURITY NUMBER |
DATE HIRED |
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STATE OF HIRE |
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ADDRESS (INCL ZIP) |
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SEX |
MARITAL STATUS |
OCCUPATION/JOB TITLE |
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UNMARRIED |
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M |
MALE |
U |
EMPLOYMENT STATUS |
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SINGLE/DIVORCED |
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F |
FEMALE |
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MARRIED |
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U |
UNKNOWN |
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SEPARATED |
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PHONE |
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# OF DEPENDENTS |
K |
UNKNOWN |
NCCI CLASS CODE |
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RATE |
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DAY |
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MONTH |
DAYS WORKED/WEEK |
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FULL PAY FOR DAY OF INJURY? |
YES |
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NO |
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PER: |
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WEEK |
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OTHER: |
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DID SALARY CONTINUE? |
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YES |
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NO |
OCCURRENCE/TREATMENT
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TIME EMPLOYEE |
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AM |
DATE OF INJURY/ILLNESS |
TIME OF OCCURRENCE |
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AM |
LAST WORK DATE |
DATE EMPLOYER |
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DATE DISABILITY |
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BEGAN WORK |
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NOTIFIED |
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BEGAN |
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PM |
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( ) CANNOT BE |
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PM |
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DETERMINED |
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CONTACT NAME/PHONE NUMBER |
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TYPE OF INJURY/ILLNESS |
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PART OF BODY AFFECTED |
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DID INJURY/ILLNESS/EXPOSURE OCCUR ON EMPLOYER’S |
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TYPE OF INJURY/ILLNESS CODE |
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PART OF BODY AFFECTED CODE |
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PREMISES? |
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YES |
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NO |
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DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE |
ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS |
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OCCURRED |
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EXPOSURE OCCURRED |
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SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR |
WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE |
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ILLNESS EXPOSURE OCCURRED |
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OCCURRED |
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HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED |
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THE EMPLOYEE OR MADE THE EMPLOYEE ILL |
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CAUSE OF INJURY CODE |
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DATE RETURN(ED) TO WORK |
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IF FATAL, GIVE DATE OF DEATH |
WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? |
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YES |
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NO |
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WERE THEY USED? |
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YES |
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NO |
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PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS) |
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HOSPITAL OR OFF SITE TREATMENT (NAME & ADDRESS) |
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INITIAL TREATMENT |
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0 |
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NO MEDICAL TREATMENT |
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MINOR: BY EMPLOYER |
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1 |
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2 |
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MINOR CLINIC/HOSP |
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EMERGENCY CARE |
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3 |
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HOSPITALIZED > 24 HOURS |
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4 |
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FUTURE MAJOR MEDICAL/ |
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5 |
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LOST TIME ANTICIPATED |
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OTHER |
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WITNESSES (NAME & PHONE #) |
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DATE ADMINISTRATOR NOTIFIED |
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DATE PREPARED |
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PREPARER’S NAME & TITLE |
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PHONE NUMBER |
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FORM |
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SEE BACK FOR IMPORTANT INFORMATION |
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IAIABC 2002 |
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AWCC Form 1
(Employer's First Report of Injury or Illness)
Ark. Code Ann. §
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
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.
Ark. Code Ann.
app licable law to the Death and Permanent Total Disability Trust Fund administered by the Workers’ Compensation Co mm ission.”
(Revised
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
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: |
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Indicate the employee’s work status. The valid choices are: |
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On Strike |
Unknown |
Volunteer |
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Disabled |
Apprenticeship |
Seasonal |
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Not Employed |
Retired |
Apprenticeship |
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 |
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 |
IAIABC 2002 |