Workers Compensation - First Report of Injury or Illness

EMPLOYER
Name: Employer FEIN:
Address: Phone:
 
 

EMPLOYEE/WAGE
* Name:    
* Address: * Date Hired (dd/mm/yyyy):
* Sex: Male Female * State of Hire:
* Date of Birth (dd/mm/yyyy): * Occupation / Job Title:
* Social Security Number: * Employment Status:
* Phone: * Average Weekly Wages:
 
 

OCCURRENCE / TREATMENT
Time Employee Began Work: Date Disability Began(dd/mm/yyyy):
Date of Injury / Illness (dd/mm/yyyy): Contact Name:
Time of Occurrence: Phone Number:
Last Work Date: Type of Injury / Illness:
Date Employer Notified (dd/mm/yyyy): Part of Body Affected: