Fill and Sign the Employers Report Workers Form

Yes. date No Yes, date last worked No Yes, date No                                                            New Jersey Registration No. Federal Employer                                                                                  MaleFemale                                                                                                                                        Day Yr STATE OF NEW JERSEY EMPLOYER'S FIRST REPORT OF ACCIDENTAL INJURY OR OCCUPATIONAL ILLNESS 1. CARRIER NAME. ADDRESS IA. POLICY NUMBER 1B. EFFECTIVE DATE EXPIRATION DATE 2. DATE OF INJURY OR ILLNESS TIME OF DAY SEND REPORT IMMEDIATELY MAIL DUPLICATE(YELLOW) TO AFTER INJURY DO NOT WAIT FOR O.S.H.A. CASE NUMBER DOCTOR'S REPORT THIS FORM (IN QUADRUPLICATE) MUST BE COMPLETED IN THE FOLLOWING CASES ONLY: (1) FOR EVERY ACCIDENTAL INJURY OF ILLNESS WHICH SHALL CAUSE A LOSS OF TIME FROM REGULAR DUTIES BEYOND THE WORKING DAY OR SHIFT INCLUDING SUNDAY OR ANY DAY ON WHICH EMPLOYEE WOULD USUALLY WORK, OR (2) WHICH SHALL REQUIRE MEDICAL TREATMENT BEYOND ORDINARY FIRST AID. OR (3) FOR THE OCCURRENCE OF AN OCCUPATIONAL ILLNESS WHETHER OR NOT TIME IS LOST.COMPLETE THIS FORM IN ACCORDANCE WITH THE INSTRUCTIONS ON BACK OF THIS WHITE SHEET. MAIL IT PROMPTLY AS POSSIBLE.IN ALL CASES NO LATER THAN THE START OF THE SECOND (2nd) WORK DAY AFTER INJURY OCCURRED, IN CASE OF A FATALOR SERIOUS INJURY (one that requires hospitalization) COMPLETE AND MAIL THIS IMMEDIATELY. PLEASE PRINT OR TYPE SEE DETAILED INSTRUCTIONS ON REVERSE SIDE (White Sheet) or 3. FIRM NAME 4. 5. S.I.C. NO. 6. NO. OF EMPLOYEES identification No. 8. TELEPHONE NO . (Area Code) 9. NATURE OF BUSINESS 7. MAILING ADDRESS (Please include City, Zip) LOCATION, IF DIFFERENT FROM MAIL ADDRESS 10. NAME: LAST NAME - FIRST NAME MIDDLE NAME 11. SOCIAL SECURITY NO. 12. Date of Birth 13. AGE 14. SEX 15. HOME ADDRESS (Number and Street, City. Zip, County) 16. OCCUPATION (Regular Job Title) Mo.17. DEPARTMENT WHERE 18. TELEPHONE NO. (Area Code) 19. WAGES 20. NO. of HRS. (Regular work day) EMPLOYED' Weekly $ Hourly $ 21. WHERE DID ACCIDENT OR EXPOSURE OCCUR? (Address, City, County) 22- WHAT WAS EMPLOYEE DOING WHEN INJURED? (Be Specific) (Please use separate sheet if necessary) 23. OBJECT OR SUBSTANCE, MACHINE OR TOOL THAT DIRECTLY INJURED EMPLOYEE 24. NATURE OF INJURY OR ILLNESS AND PART OF BODY AFFECTED (Formal Diagnosis Not Required) 25. 010 EMPLOYEE DIE? 26. WAS EMPLOYEE UNABLE TO WORK ON ANY DAY AFTER INJURY? 27. HAS EMPLOYEE RETURNED TO WORK? 28. NAME OF TREATING DOCTOR. IF ANY 29. DOCTOR'S ADDRESS: (Number and Street. City. Zip) 30. IF HOSPITALIZED. Name of Hospital 31. ADDRESS OF HOSPITAL (Number and Street. City. ZIP) COMPLETED BY: (Print or Type) TITLE: IMPORTANT NOTICE OF SPECIAL FILING RIGHTS FOR UNEMPLOYMENT INSURANCE BENEFITS SIGNATURE: DATE: The New Jersey Unemployment Compensation Law provides special filing rights for workers upon recovery from a work-relatedinjury or illness. NEW JERSEY DEPARTMENT OF LABOR DIVISION OF WORKERS' COMPENSATION MAIL Eligibility for unemployment insurance benefits may be based upon wages earned prior to your disability. CN 381 ORIGINAL TRENTON, NEW JERSEY 08625-0381(White) TO NOTE. THESE BENEFITS ARE POTENTIAL UNEMPLOY-MENT INSURANCE BENEFITS. YOU SHOULD CON-TACT THE DIVISION OF PROGRAMS - UNEMPLOY-MENT AND DISABILtTY INSURANCE FORADDITIONAL INFORMATION. DO NOT CONTACTTHE DIVISION OF WORKERS' COMPENSATION. BLUE COPY RETAINED BY EMPLOYEE.PINK COPY FOR PERSONNEL RECORDS. FILING OF THIS REPORT IS NOT AN ADMISSION OF LIABILITY L & 1-1 (R-6-92) INSTRUCTIONS 1 . CARRIER NAME, ADDRESS: Indicate the name and address of the firm's Workers' Compensation carrier. if self-insured, indicate *self- insured''. 1A. POLICY NUMBER : Indicate the firm's Workers' Compensation Insurance policy number. 1B. EFFECTIVE DATE: Indicate the date when the present policy started. EXPIRATION DATE: Indicate the date when the present policy expires. 2. DATE OF INJURY OR ILLNESS: Indicate the date when the injury occurred or in case of illness, when first detected. TIME OF DAY: Indicate the time of injury or illness (i.e. 9:30 a.m. or 7:00 p.m.) O.S.H.A. CASE NUMBER: (Leave Blank) 3. FIRM NAME: Indicate the full name of individual, partnership, corporation or trade name of the employer. 4. NEW JERSEY REGISTRATION NUMBER OR FEDERAL EMPLOYER IDENTIFICATION NUMBER: Indicate either your company's New Jersey Registration Number or your company's Federal Employer Identification Number. This number can be obtained from your copy of QuarterlyReport of Wages (Form U.C. 27B). The account number is on the fifth line of the address. S. S.I.C. Number: Indicate the S.I.C. Number of your firm. This number can be obtained from your copy of Quarterly Report of Wages (Form U.C. 27B). The S.I.C. isthe four digit number in the lower right hand corner of the address under the account number. 6. NO. OF EMPLOYEES: The number of employees employed by the firm. 7. MAILING ADDRESS: The address of the employer. 8. TELEPHONE NO. (AREA CODE): The business telephone of the employer. 9. NATURE OF BUSINESS: Describe the kind of business of the employer, i.e. manufacture shoes, wholesale food, retail clothing, construction, transportation, communication, utilities, government, etc. LOCATION, IF DIFFERENT FROM MAILING ADDRESS: If the location where the injury or illness occurred is different from the mailing address of the employer in question #3. 10. NAME : Indicate the full name of the employee as carried on payroll records. 11. SOCIAL SECURITY NO .: Indicate the Social Security number of the employee. 12. DATE OF BIRTH: 13. AGE: 14. SEX: (Self-explanatory) 15. HOME ADDRESS: The address of the employee. 16. OCCUPATION: The job classification of employee, i.e., carpenter, electrician, driver, lathe operator, salesperson, etc. 17. DEPARTMENT-WHERE EMPLOYED: indicate under which agency within the firm that the employee worked. 18. TELEPHONE NO.-, The home telephone of employee. 19. WAGES: if employee is paid weekly salary indicate gross weekly amount. If employee is paid hourly indicate hourly rate. (exclude overtime) 20. NO. OF HOURS : Indicate the total regular number of hours employee works per day. (exclude overtime) 21. WHERE DID ACCIDENT OR EXPOSURE OCCUR? If the location of accident or exposure is different from the address shown on line 7, give sufficient information to pinpoint location by giving address, city, county, route orjob location. 22. WHAT WAS EMPLOYEE DOING WHEN INJURED? Examples: walking down stairs, climbing ladder, operating table saw, changing wheel on grinder, sitting at desk, opening file drawer, etc. 23. OBJECT OR SUBSTANCE, MACHINE OR TOOL THAT DIRECTLY INJURED EMPLOYEE Examples: stairs and handrail, floor, saw blade, dust, vapors, chips, chisel, hammer, chain, acid (name), steam, fire, hot sluge, electric current, the item employee was lifting, pushing or pulling,etc. 24. NATURE OF INJURY OR ILLNESS AND PART OF BODY AFFECTED Examples: amputation of right index finger, fracture of ribs, burn of left hand, contusions of both legs, laceration of upper right arm, etc. Examples of occupational disease: dermatitis of neck, silicosis, etc. 25. DID EMPLOYEE DIE? Was the injury or illness the cause of death? 26. WAS EMPLOYEE UNABLE TO WORK ON ANY DAY AFTER INJURY? (Self-explanatory). 27. HAS EMPLOYEE RETURNED TO WORK? (Self-explanatory). 28, 29, 30, 31 (Self-explanatory)