Fill and Sign the Bill of Sale Form South Carolina First Report of Injury or Illness

WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS CARRIER/ADMINISTRATOR CLAIM NUMBER OSHA LOG NUMBER REPORT PURPOSE CODE JURISDICTION JURISDICTION CLAIM NUMBER INSURED REPORT NUMBER EMPLOYER (NAME & ADDRESS INCL ZIP) LOCATION # INDUSTRY CODE EMPLOYER FEIN EMPLOYER’S LOCATION ADDRESS (IF DIFFERENT) PHONE # CARRIER/CLAIMS ADMINISTRATOR CARRIER (NAME, ADDRESS, & PHONE #) CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO) POLICY PERIOD 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 SEX MARITAL STATUS OCCUPATION/JOB TITLE M U UNMARRIED SINGLE/DIVORCED EMPLOYMENT STATUS F M ADDRESS (INCL ZIP) U MALE FEMALE UNKNOWN S MARRIED SEPARATED K PHONE # OF DEPENDENTS UNKNOWN NCCI CLASS CODE YES RATE PER: DAY WEEK MONTH OTHER: DAYS WORKED/WEEK FULL PAY FOR DAY OF INJURY? DID SALARY CONTINUE? YES NO NO OCCURRENCE/TREATMENT TIME EMPLOYEE BEGAN WORK AM PM DATE OF INJURY/ILLNESS TIME OF OCCURRENCE ( ) CANNOT BE DETERMINED AM PM LAST WORK DATE DATE EMPLOYER NOTIFIED DATE DISABILITY BEGAN CONTACT NAME/PHONE NUMBER TYPE OF INJURY/ILLNESS PART OF BODY AFFECTED DID INJURY/ILLNESS/EXPOSURE OCCUR ON EMPLOYER’S PREMISES? TYPE OF INJURY/ILLNESS CODE PART OF BODY AFFECTED CODE YES NO DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE 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 NO DATE RETURN(ED) TO WORK IF FATAL, GIVE DATE OF DEATH WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? WERE THEY USED? YES YES NO INITIAL TREATMENT 0 1 2 3 4 PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS) HOSPITAL OR OFF SITE TREATMENT (NAME & ADDRESS) 5 NO MEDICAL TREATMENT MINOR: BY EMPLOYER MINOR CLINIC/HOSP EMERGENCY CARE HOSPITALIZED > 24 HOURS FUTURE MAJOR MEDICAL/ 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 FORM IA-1(r 1-1-02) IAIABC 2002 EMPLOYER’S INSTRUCTIONS DO NOT ENTER DA TA IN SHA DED FIELDS DAT ES: Enter all dates in MM/DD/YY format. INDUSTRY CODE: This is the code w hich represents the nature of the employer’s business, w hich 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 assumin\ g 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 know n. This information can be found on your insurance policy. OCCUPAT ION/JOB T ITLE: This is the primary occupation of the claimant at the time of the accide\ nt or ex posure. EMPLOYMENT ST AT US: Indicate the employee’s w ork status. The valid choices are: Full-Time On Strike Unknow n Volunteer Part-Time Disabled Apprenticeship Full-Time Seasonal Not Employed Retired Apprenticeship Part-Time Piece Worker DAT E DISABILIT Y BEGAN: The first day on w hich the claimant originally lost time from w ork due to the occupation injury or disease or as otherw ise designated by statute. CONTACT NAME/PHONE NUMBER: Enter the name of the individual at the employer’s premises to be con\ tacted for additional information. TYPE OF INJURY/ILLNESS: Briefly describe the nature of the injury or illness, (eg. Lacerations \ to the forearm). PART OF BODY AF FECT ED: Indicate the part of body affected by the injury/illness, (eg. Right fo\ rearm, low er back). DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED: (eg. Maintenance Department or Client’s office at 452 Monroe St., Wa\ shington, DC 26210) If the accident or illness ex posure did not occur on the employer’s premises, enter address or loc\ ation. Be specific. FORM IA-1(r 1-1-02) IAIABC 2002 EMPLOYER’S INSTRUCTIONS – cont’d ALL EQUIPMENT , MAT ERIAL OR CHEMICALS EM PLOYEE 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 w as using, applying, handling or operating when the injury or illness occurred. Be specific, for ex ample: decorator’s scaffolding, electric sander, paintbrush, and paint. Enter “NA” for not applicable if no equipment, materials, or chemi\ cals w ere being used. NOTE: The items listed do not have to be directly involved in the employee’s injury or illne\ ss. SPECIF IC ACT IVIT Y THE EMPLOYEE WAS ENGAGED IN WHEN T HE ACCIDENT OR ILLNESS EXPOSURE OCCURRED: (eg. Cutting metal plate for flooring) Describe the specific activity the employee w as engaged in w hen the accident or illness ex posure occurred, such as sanding ceiling w oodw ork in preparation for painting. WORK PROCESS T HE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED: Describe the w ork process the employee w as engaged in w hen the accident or illness ex posure occurred, such as building maintenance. Enter “NA” for not applicable if employe\ e w as not engaged in a w ork process (eg. walking along a hallw ay). HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE \ SEQUENCE OF EVENT S AND INCLUDE ANY OBJECT S OR SUBST ANCES T HAT DIRECT LY INJURED T HE EMPLOYEE OR MADE THE EMPLOYEE ILL: (Worker stepped back to inspect w ork and slipped on some scrap metal. As w orker fell, w orker 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 ex ample: Worker stepped to the edge of the scaffolding to inspect w ork, lost balance and fell six feet to the floor. The worker’s right w rist w as broken in the fall. DATE RETURN(ED) TO WORK: Enter the date follow ing to most recent disability period on w hich the employee returned to w ork.