Fill and Sign the Dwc Form 001 Employers First Report of Injury or Illness

DWC FORM-001 Rev. 10/05 Page 1 DWC FORM-001 (Employer's First Report of Injury or Illness) The employer is required to file an Employer's First Report of Injury or Illness [DWC FORM-001 Rev. 10/05] with the injur ed worker's insurance carrier, and the injured claimant or the claimant's representative within 8 days after the employee's absence from work or receipt of notice of occupational disease. The Employer's First Report of Injury or Illness provides information on the claimant, employer, insurance carrier and medical practitioner necessary to begin the claims process. Details of the claimant's employment and circumstances surrounding the injury or illness are also requested. Send the specified copies to your Workers' Compensation Insurance Carrier and the injured employee. *Employers - Do not send this form to the Texas Department of Insurance, Division of Workers' Compensation, unless the Division specifically re quests a direct filing. [Workers' Compensation Rule 120.2] DWC FORM-001 Rev. 10/05 Page 2 INSTRUCTIONS FOR EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS (DWC FORM-001) Type (or print in black ink) each item on this form. Failure to complete each item may delay the processing of the injury clai m. Section 409.005, Texas Workers' Compensation Act, requires an Empl oyer's First Report of Injury or Illness (DWC FORM-001 Rev. 10/05 to be filed with the Workers' Compensation Insurance Carrier not late r than the eighth day after the receipt of notice of occupational disease, or the employee's first day of absence from work due to injury or death. A copy of this report must be sent to the employee or the employee's representative. For purposes of this section, a report is fil ed when personally delivered, or postmarked. Send the specified copies to your Workers' Compensation Insurance Carrier and the injured employee. *Employers - Do not send this form to the Texas Department of Insurance, Division of Workers' Compensation, unless the Division specifically requests a direct filing. If a report has not been received by the carrier, the employer has the burden of proving that the report was filed within the required time fram e. The employer has the burden of proving that good cause exist ed if the employer failed to file the report on time. An employer who fails to file the report without good cause may be assessed an administrative penalty. An employer who fails to file the report without good cause waives the right to reimbursement of vol untary benefits even if no administrative penalty is assessed. Once the employer has completed all information pertaining to the injury the employer should maintain the copy of this report to serve as the Employer's Record of Injury required by Secti on 409.006. Send the specified copies to your Workers' Compensation Insurance Carrier and the injured employee. *Employers - Do not send this form to the Texas Department of Insurance, Division of Workers' Compensation, unless the Division specifically requests a direct filing. The Division’s Health and Safety will use data from this report for the Job Safety Information System established in Section 411. 032 of the Texas Workers' Compensation Act. This report may not be considered admission or evidence against the employer or the insurance carrier in any proceeding before the Division or a court in which facts set out in the report are c ontradicted by the employer or insurance carrier. "SPECIAL INSTRUCTIONS FOR CERTAIN ITEMS" Items 2,7,8: Section 402.082, Texas Workers' Compensation Act requires the Division to maintain information as to the race, eth nicity and sex on every compensable injury. This information will be maintained for non-discriminatory statistical use. Item 4: If no home phone, please provide a phone number where the employee can be reached. Items 5,15,17, 26,29,30: Enter data in month, day, year format. Example: 08-13-54. Item 18: List nature of accident or exposure, e.g., fall from sca ffold, contact with radiation, etc. If occupational disease, so state. Item 19: List specific body part, e.g., chin , right leg, forehead, left upper arm, etc. If more than one body part is affected, list each part. Item 20: Describe in detail (1) the events leading up to the inju ry/illness, (2) the actual injury, e.g., cut left forearm, broken right foot, etc., and (3) the reason(s) why accident/injury occurred. Use an additional sheet of paper if necessary. Item 22: State the exact work-site locati on of the injury, e.g., construction site, office area, storage area, etc. Item 24: List object, substance, or exposure that directly infl icted the injury or illness, e.g., floor, hammer, chemicals, etc . Items 32,33: Enter date in month- year format. Example: 02-56. Item 37: Enter the number of days or hours that make up a full work week for your employees. Item 45: Enter the 6-digit North American Industry Classification Sy stem (NAICS) Code of the employer. The primary code is the code which appears in block 5 of Form C-3, "Employer's Q uarterly Report" to the Texas Workforce Commission. Item 46: For companies with a single NAICS code, the specific co de is the same as the primary code. For companies with multiple NAICS codes, enter the code t hat identifies the specific business, activity, or work-site location the employee was working i n at the time of the injury. This may or may not be the same as the primary code. Send the specified copies to your Workers' Compensation Insurance Carrier and the injured employee. *Employers - Do not send this form to the Texas Department of Insurance, Di vision of Workers’ Compensation, Unless the Division specifically requests a direct filling. CLAIM # ______________________________________ CARRIER'S CLAIM # EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS 1. Name (Last, First, M.I.) 2. Sex F M 15. Date of Injury (m-d-y) - - 16. Time of Injury : am pm 17. Date Lost Time Began (m-d-y) - - 3. Social Security Number - - 4. Home Phone ( ) 5. Date of Birth (m-d-y) - - 18. Nature of Injury* 19. Part of Body Injured or Exposed* 6. Does the Employee Speak English? If No, Specify Language YES NO 20. How and Why Injury/Illness Occurred* 7. Race White Black Asian 8. Ethnicity Hispanic Native American Other 21. Was employee doing his YES regular job? NO 22. Worksite Location of Injury (stairs, dock, etc.)* 9. Mailing Address Street or P.O. Box City State Zip Code County 23. Address Where Injury or Exposure Occurred Name of business if incident occurred on a business site Street or P.O. Box County 10. Marital Status Married Widowed Separated Single Divorced City State Zip Code 11. Number of Dependent Ch ildren 12. Spouse's Name 24. Cause of Injury(fall, tool, machine, etc.)* 13. Doctor's Name 25. List Witnesses 14. Doctor's Mailing Address (Street or P.O.Box) City State Zip Code 26. Return to work date/or expected (m-d-y) - - 27. Did employee die? YES NO 28. Supervisor's Name 29. Date Reported (m-d-y) - - 30. Date of Hire (m-d-y) - - 31. Was employee hired or recruited in Texas? YES NO 32. Length of Service in Current Position Months Years ______ 33. Length of Service in Occupation Months Years ______ 34. Employee Payroll Classification Code 35. Occupation of Injured Worker 36. Rate of Pay at this Job $ Hourly $ Weekly 37. Full Work Week is: Hours Days 38. Last Paycheck was: $ for Hours or Days 39. Is employee an Owner, Partner, or Corporate Officer? YES NO 40. Name and Title of Person Completing Form 41. Name of Business 42. Business Mailing Address and Telephone Number Street or P.O. Box Telephone ( ) 43. Business Location (If different from mailing address) Number and Street City State Zip Code City State Zip Code 44. Federal Tax Identification Number 45. Primary North American I ndustry Classification System Code: (6 digit) 46. Specific NAICS Code (6 digit) 47. Texas Comptroller Taxpayer No. 48. Workers' Compensation Insurance Company 49. Policy Number 50. Did you request accident preventio n services in past 12 months? YES NO If yes, did you receive them? YES NO 51. Signature and Title (READ INSTRUCTIONS ON INSTRUCTION SHEET BEFORE SIGNING) X Date ________________________________________ DWC FORM-1 (Rev. 10/05) Page 3 DIVISION OF WORKERS’ COMPENSATION