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 |      |(   )    -     |      |

| | | | |

| |Mailing Address: |Claim Number: |Insurer FEIN: |

| |      |      |      |

| |      | | |

| |      | | |

| | |Claim Administrator FEIN: |Claim Type Code: |

| | |      |      |

|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 |      | |

| |      |      | | |

| |      |      | | |

| | | | | |

| | | |Insured Location No. | |

| | | |      | |

| | | | | |

| |Nature of Business: |Employer Contact Name and Phone: |

| |      |      (   )    -     |

| | | |

|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: | |

| | | | | |      | |

| | | | | | | |

|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) |

| | | | | |

| |Mailing Address, City State, Zip |Date of Hire: | | |

| |      | | | |

| |      |      | | |

| | | |Educational Level (grade completed {GED=12}: |Marital Status |

| | | |    |(Check One) |

| | | | | |

| | | | |Unmarried (U) |

| | | | |Married (M) |

| | | | |Separated (S) |

| | | | | |

| |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 | |

| | | | | |

| |Occupational Description: | | | |

| |      | | | |

| | | | | |

| | | | |Employee’s Authorization |

| | | | |to Release the following: |

| | | | | |

| | | | |Medical Records |

| | | | |Yes No |

| | | | |Soc. Sec. Number |

| | | | |Yes No |

| |Manual Class Code: | | | |

| |      | | | |

| | | | | |

| |Dept. where regularly worked: | | | |

| |      | | | |

| | | | | |

|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: | |

| |   |$      | |

| | | | |

|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) | |

| | | |

| | | |

| | | |

| | | |

| | |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) |

| | |      |

| | | |

| |Accident Premises Code: | |

| |Employer (E) | |

| |Lessee (L) | |

| |Other (X) | |

| | |Name the object or substance that directly injured the employee (ex: knife, floor, acid, oil) |

| | |      |

| | | |

| |Accident Site Organization Name: | |

| |      | |

| | | |

| |Accident Site Street, City, State, Zip: | |

| |      | |

| |      | |

| |      | |

| | | |

| | |Specify activity in which employee was engaged when event occurred: (ex: cutting metal plate for|

| | |flooring). Indicate if activity was part of normal duties: |

| | |      |

| | | |

| | | |

| |Accident Location Narrative (if no street address: | |

| |      | |

| | | |

| |Accident Site County/Parish: |Witness name and business phone number: |

| |      |     , (   )    -     |

| | | |

|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) | | |

| | | | |

| | | | |

| | |Initial Medical Provider Physical Address, City, State, Zip | |

| | |      | |

| | |      | |

| | |      | |

| | | |ICD Primary Code (if |

| | | |known):       |

| | | | |

| |Preparer’s Name & Title: |Preparer’s Company Name: |Phone: |Date: |

| |      |      |(   )    -     |      |

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