Iowa Workers’ Compensation – FIRST REPORT OF INJURY OR ...
Iowa Workers’ Compensation – FIRST REPORT OF INJURY OR ILLNESS Jurisdiction Code: Jurisdiction Claim Number:
|CLAIM |Claim Administrator Name: |Claim Rep Phone: |Insurer: |
|ADMIN | |( ) - | |
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| |Mailing Address: |Claim Number: |Insurer FEIN: |
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| | |Claim Administrator FEIN: |Claim Type Code: |
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|EMPLOY|Employer Name: |Employer FEIN: |Insured Rept No: |Employer Type Code: |
|ER | | | | |
| | | | |Employer (E) |
| | | | |Lessor (L) |
| | | | | |
| |Physical Address, City, State, Zip Code |Mailing Address, City, State, |Industry Code: | |
| | |ZIP | | |
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| | | |Insured Location No. | |
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| |Nature of Business: |Employer Contact Name and Phone: |
| | | ( ) - |
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|POLICY|Insured Name (parent company if different |Insured FEIN: |Insured ZIP |Policy/Contract Number: |Coverage Effective Date: |Self Insurance |
| |than employer): | | | | |License/Cert No.: |
| | | | | | | |
| | | | | |Coverage Expiration Dt: | |
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|EMPLOY|Employee Name (First, Middle, Last & Suffix): |Birth Date: |Gender |Tax Filing Status (check one): |
|EE | | | |Single (A) Married/Filing Joint (C) |
| | | |Male (M) |Single/Head of Married/Filing Separate (D) |
| | | |Female (F) |Household (B) |
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| |Mailing Address, City State, Zip |Date of Hire: | | |
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| | | |Educational Level (grade completed {GED=12}: |Marital Status |
| | | | |(Check One) |
| | | | | |
| | | | |Unmarried (U) |
| | | | |Married (M) |
| | | | |Separated (S) |
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| |Phone Number (inc. area code) |Employment Status (check one) |Employee ID No. (check one) | |
| |( ) - |Piece worker | | |
| | |Volunteer |ID#: | |
| | |Seasonal | | |
| | |Apprentice Full-Time |Social Security Number | |
| | |Apprentice Part-Time |Employment Visa No.# | |
| | |Regular Full-Time |Passport Number | |
| | |Part-Time |Green Card | |
| | |Other |Employee ID assigned by | |
| | | |jurisdiction | |
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| |Occupational Description: | | | |
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| | | | |Employee’s Authorization |
| | | | |to Release the following: |
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| | | | |Medical Records |
| | | | |Yes No |
| | | | |Soc. Sec. Number |
| | | | |Yes No |
| |Manual Class Code: | | | |
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| |Dept. where regularly worked: | | | |
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|WAGE |Average Wage $ (check one): |Salary Continued in Lieu of Compensation: |Employee Number of |
| | |Yes No |Dependents: |
| |Hourly daily semimonthly monthly | | |
| |Bi-weekly annual weekly | | |
| | | | |
| | |Full Wages Paid for Date of Injury |Employee Number of |
| | |Yes No |Exemptions: |
| | | |Entitled |
| | | |Withholding |
| | | | |
| |Number of Days Regularly Worked Per Week: |Discontinued Fringe Benefits: | |
| | |$ | |
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|ACCIDE| Date of Injury |Describe the nature of the injury. (ex: amputation, burn, cut, fracture): |
|NT/INJ| Date Employer had knowledge of the Injury | |
|URY | Date Claim Administrator had knowledge of Injury | |
| | Initial Date Last Day worked | |
| | Initial Return to work Date (if applicable) | |
| | Employee Date Of Death (if applicable) | |
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| | |Part(s) of body directly affected by the injury or illness (ex: hand, arm, circulatory system) |
| | | |
| | Time of Injury | |
| | Time Employee Began Work | |
| | | |
| |Preexisting Disability Code: | |
| |Yes | |
| |No | |
| |Unknown | |
| | |Describe the event causing the injury: (ex: fell, operating machinery, chemical exposure) |
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| |Accident Premises Code: | |
| |Employer (E) | |
| |Lessee (L) | |
| |Other (X) | |
| | |Name the object or substance that directly injured the employee (ex: knife, floor, acid, oil) |
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| |Accident Site Organization Name: | |
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| |Accident Site Street, City, State, Zip: | |
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| | |Specify activity in which employee was engaged when event occurred: (ex: cutting metal plate for|
| | |flooring). Indicate if activity was part of normal duties: |
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| |Accident Location Narrative (if no street address: | |
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| |Accident Site County/Parish: |Witness name and business phone number: |
| | | , ( ) - |
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|MEDICA|Initial Treatment Code (check one): |Initial Medical Provider Name: |Managed Care Organization |
|L |No medical treatment (0) | |Name or ID: |
| |Minor/on-site treatment (1) | | |
| |Clinic/Hospital Visit (2) | | |
| |Emergency Care (3) | | |
| |Hospitalization >24 hrs (4) | | |
| |Future medical treatment/lost time anticipated (5) | | |
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| | |Initial Medical Provider Physical Address, City, State, Zip | |
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| | | |ICD Primary Code (if |
| | | |known): |
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| |Preparer’s Name & Title: |Preparer’s Company Name: |Phone: |Date: |
| | | |( ) - | |
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