Fill and Sign the Colorado Employer Form

COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS’ COMPENSATION EMPLOYER’S FIRST REPORT OF INJURY Employee’s name (first, middle, last) Social Security # □ Male □ Female Employee’s home phone # ( ) OSHA Log # Employee’s street address City State Zip code Birth date / / Marital status Date of hire / / Occupation Employment status For Division use only□ Married □ Single □ Separated □ Unknown □ Full time □ Other □ Part time □ Unknown Employer’s name Employer’s Federal ID # Employer’s phone # ( ) SOI Employer’s mailing address City State Zip code POB Average weekly wage at time of injury Check box if employee receives Check if these benefits are included in AWW NOI $___________________ (see instructions on reverse side) □ Tips □ Room □ Meals □ Health insurance □ Tips □ Room □ Meals □ Health insurance Coder Is the employer self-insured? □ Yes □ No Were full wages paid for the DOI? □ Yes □ No Are wages continued per C.R.S. 8-42-124? 1 □ Yes □ No Injury/Illness date / / (See instructions on reverse side) Time employee began work ____ ___ □ a.m. ____ ___ □ p.m. Injury time ____ ___ □ a.m. ____ ___ □ p.m. □ unknown Last day worked / / Date employer notified / / Date disability began / / Date returned to work / / Did injury cause death? □ Yes □ No If so, date of death / / Name, relationship, and address of closest dependent if injury caused death Injury occurred because of □ Intoxication □ Safety violation □ Not applicable Tell us the part of body that was affected Tell us the nature of the injury/illness 2 What was the employee doing just before the accident occurred? 3 Tell us how the injury occurred 4 What object or substance directly harmed the employee? 5 Did injury occur on premises? Injury site address/ 9-digit zip code Initial treatment (check one) Was the employee hospitalized overnight as an in-patient? □ Yes □ No □ None □ Minor on-site □ Clinic/hospital □ Emergency room □ Hospital >24 hrs □ Yes □ No Names of witnesses Name of employer representative notified Name and address of treating doctor or other health care professional Name and address of facility where treated Completed by (name) Title Phone # ( ) Date completed / / The following is to be completed by the insurer prior to filing with the Division of Workers’ Compensation. Name of insurance company Address Name of third party administrator (if applicable) Address Adjuster name Adjuster phone # Policy # Carrier claim # Date insurer received first report / / Block # Adj. Code WC 1 Rev 01/06 See instructions on reverse side before completing form. INSTRUCTIONS This form contains all items requested on OSHA Form No. 301, “Injuries & Illnesses Incident Report” General  All injuries no matter how trivial must be reported to your insurance company.  All injuries or occupational diseases which result in lost time from work in excess of three shifts or calendar days, or in permanent physical impairment, must be reported to your insurance carrier on this form within ten days after notice or knowledge of the injury or disease. Fatalities must be reported to your insurance carrier immediately.  Forms should be typed or printed legibly.  All questions must be answered completely to meet requirements of the Colorado Workers’ Compensation Act and to conform to the OSHA requirements for Form No. 301.  The employer has the right in the first instance, to select the physician who attends the injured employee. Calculation of Average Weekly Wage  Determine the weekly wage rate.  Add the average weekly amount of any overtime wages, tips or commissions.  Add the average weekly value of any board, rent, housing, or lodging provided by the employer if the employer will not be paying such benefit during the period of disability.  If the employee is covered by group health insurance and the employer does not continue the employee’s health insurance coverage during the period of disability, add the employee’s cost of conversion to a similar or lesser insurance plan and include this cost in the average weekly wage computation.  Compute the total from the above categories and insert in the Average weekly wage at time of injury field. Injury Date Information In the case of an occupational disease, use the date of the last injurious exposure. Notes Are Wages continued per C.R.S. 8-42-124? 1 (Subject to application with and approval of the Director of the Colorado Division of Workers’ Compensation) 1 Any employer who, by separate agreement, working agreement, contract of hire, or any other procedure, continues to pay a sum in excess of the temporary total disability benefits to an employee temporarily disabled as a result of a work related injury or disease , and has not charged the employee with any earned vacation leave, sick leave, or other similar benefits, shall be reimbursed if insured by an insurance carrier or shall take credit if self-insured, to the extent of all moneys that such employee may be eligible to receive as compensation for temporary partial or temporary total disability subject to the approval of the Director of the Colorado Division of Workers’ Compensation. Injury Description (Tell us the part of body that was affected. Tell us the nature of the injury/illness 2 ; What was the employee doing just before the accident occurred? 3 ; What happened? 4 ; What object or substance directly harmed the employee? 5 ) 2 Be more specific than “”hurt”, “pain”, or “sore.” Examples: “strained back”; “chemical burn, hand”; “carpal tunnel syndrome.” 3 Describe the activity, as well as the tools, equipment or material the employee was using. Be specific. Examples: “climbing a ladder while carrying roofing materials”; “spraying chlorine from hand sprayer”; or “daily computer key-entry.” 4 Tell us how the injury occurred. Examples: “When ladder slipped on wet floor, worker fell 20 feet”; “Worker was sprayed with chlorine when gasket broke during replacement”; “Worker developed soreness in wrist over time.” 5 Examples: “concrete floor”; “chlorine”; “radial arm saw.” If this question does not apply to the incident, leave it blank Notices You are hereby notified that if a child support obligation is owed, compensation benefits may be attached and payment of the child support obligation may be withheld and forwarded to the obligee pursuant to sections 8-42-124 and 26-13-122(4), C.R.S. YOU ARE FURTHER NOTIFIED that you must provide written notice of any award for social security, pension, disability or other source of income that might reduce your compensation benefits. This notice must be sent to the insurance carrier or self-insured employer within 20 days after learning of the payment or award. Failure to report may result in suspension of your benefits pursuant to section 8-42-113.5, C.R.S. C.R.S. Section 10-1-128(6) (a) states: “It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purposes of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.” WC 1 Rev 01/06