Fill and Sign the Employee Injury and Treatment Form

REPORT OF OCCUPATIONAL INJURY OR ILLNESS Employee: Answer Questions 1-17, immediately mail report1. Last Name First Name Initial 2. Telephone Number 3. Date of Birth 4. Sex Male Female 5. Social Security Number - - 6. Mailing Address: 7. Residence Address: 8. City, Town, Village where injury occurred: 9. Date and hour of last exposure to injury or disease: 2 10. On employer’s premises? YesNo 11. Full Name and Address of Attending Physician: 12. Hospitalized as In-Patient: Yes No 13. Name and Address of Hospital: 14. Type of Injury or illness and part of body injured: Left Right 15. Describe how the injury or illness happened: 16. Employee’s Signature: ______________________________________17. Date Signed: Employer: Answer Questions 18-4918. Employer’s Name and Telephone Number: 19. Employer’s Address( if different from mailing): 20. Employer’s Mailing Address: 21. Name of Insurer: 22. Full Name and Address of Adjusting Company: 23. Mailing Address of Adjusting Company: 24. Date Employer First Knew Injury or Illness was Work Related: 25.Time Employee Left Work: 26. Time Lost Beyond Date of Injury or Illness: 27. Date Returned to Work: 228. Death Yes No Date: 29. Location Where Injury or Illness Took Place: 30. Employee’s Occupation: 31. Date Hired by Employer: 32. Earnings Calculated By: Hr. Day Output Wk. Mo. Year 33. Rate of Pay: 34. Days Employee Works per Week: 3 or Less 4 5 6 7 35. Name Scheduled Days Off: 36.Work Day Began: 37. Was Employee Paid for Day of Injury or Illness? Yes No 38. Federal EIN Number: 39. Give Details of How Injury or Illness Happened: 240. Was Injury or Illness Caused by Failure of a Machine or Product? Yes No 41. Were Mechanical Guards or Other Safeguards Provided? Yes No 42. Name Machine, Substance, or Object which Injured Employee: 43. If Mechanical, Specify Which Part: 44. Names and Addresses of Witnesses: 45. If the Injury Was Caused by Anyone Besides Employee, Give Name and Address: 46. Dependents (name and address in case of death): 47. If you Doubt Validity of Injury or Illness, Please State Why: 48. Signature of Authorized Employer Representative: ______________________________________________________________48. Title: 49. Date Signed: