Fill and Sign the Employers Report of Occupational Injury or Aigcom Form

COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG PA 17104-2501 (TOLL FREE; 800-482-2383 TTY (TOLL FREE) 800-362-4228 EMPLOYER'S REPORT OF OCCUPATIONAL INJURY OR DISEASE EMPLOYEE SOCIAL SECURITY NUMBER DATE OF INJURY MONTH DAY YEAR EMPLOYEE FIRST NAME EMPLOYEE LAST NAME STREET ADDRESS CITY STATE ZIP CODE COUNTY PHONE NUMBER EMPLOYEE: NUMBER OF DEPENDENTS DATE OF BIRTH MALE MARRIED FEMALE SINGLE MONTH DAY YEAR OCCUPATION OR JOB TITLE NCCI CLASS CODE (IF KNOWN) EMPLOYMENT STATUS FT = Full-time SL = Seasonal PT = Part-time VO = Volunteer ZZ = Other EMPLOYER STREET ADDRESS CITY ZIP CODE STATE PHONE NUMBER EMPLOYER FEIN SIC CODE COUNTY FULL PAY FOR DAY OF INJURY? TIME EMPLOYEE BEGAN WORK TIME OF OCCURRENCE AM AM YES NO PM PM 344 1197-1 DATE DISABILITY BEGAN LAST DAY WORKED MONTH MONTH YEAR DAY YEAR DAY DATE RETURNED TO WORK DATE EMPLOYER NOTIFIED MONTH YEAR DAY YEAR DAY CONTACT FIRST NAME CONTACT PHONE NUMBER CONTACT LAST NAME NOTICE: Report should be clearly completed, (preferably typed) and original mailed to the Bureau at the address in the upper left corner and a copy to employee and insurer. LIBC-344 REV 1-01 (OVER) MONTH LIBC 344 TYPE OF INJURY CODE PART OF BODY AFFECTED CODE CAUSE OF INJURY CODE (ENTER CODES, IF KNOWN) TYPE OF INJURY OR ILLNESS PARTS OF BODY AFFECTED CAUSE OF INJURY IF OUT OF STATE SPECIFY STATE OF INJURY DID INJURY OR ILLNESS OCCUR ON EMPLOYERS PREMISES? WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? WERE SAFEGUARDS OR SAFETY EQUIPMENT USED? YES YESYES NO NONO ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING 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 DIRECTLY RESPONSIBLE INITIAL TREATMENT IF FATAL, GIVE DATE OF DEATH NO MEDICAL TREATMENT MINOR BY EMPLOYEE MONTH YEAR DAY CLINIC / HOSPITAL PHYSICIAN/HEALTH CARE PROVIDER PANEL PHYSICIANFIRST NAME: LAST NAME: EMPLOYEE PHYSICIAN STREET EMERGENCY CARE HOSPITALIZED MORE THAN 24 HOURS STATE ZIP CITY POLICY PERIOD FROM: HOSPITAL NAME: MONTH DAY YEAR STREET POLICY PERIOD TO: STATE ZIP CITY MONTH DAY YEAR POLICY/SELF INSURED NUMBER: WITNESS PHONE NUMBER WITNESS FIRST NAME WITNESS LAST NAME INSURANCE CARRIER OR THIRD PARTY ADMINISTRATOR (IF SELF-INSURED) PERSON COMPLETING THIS FORM: NAME: NAME: TITLE: STREET PHONE: STATE ZIP CITY FEIN: BUREAU CODE: DATE PREPARED MONTH YEAR DAY Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165. 344 1197-2