Fill and Sign the Kentucky Report Injury 497308147 Form

                                                                                                                                                                                                                                                                                                                                                                                                                                                      General Carrier/Claims Admin Employee/Wage Occurrence Treatment Other IA-1WORKERS COMPENSATION - FIRST REPORT OF INJURY OR ILLNESS Employer (Name & Address incl. zip) Carrier Administrator Claim Number Report Purpose Code Jurisdiction Jurisdiction Claim Number Insured Report Number Employer's Location Address (if different) Location No. Sic Code Employer FEIN Phone No. Carrier (Name, Address & Phone Number) Policy Period Claims Admin (Name, Address & Phone Number) TO Check if self insured Carrier FEIN Policy Number or Self-Insured Number Administrator FEIN Agent Name & Code Number Legal Name (Last, First, Middle) Date of Birth Social Security Number Date Hired State of Hire Address (Incl. Zip) Sex Marital Status Occupation/Job Title Male Unmarried/Sinqle/Div. Female Married Employment Status Unknow n Separated Phone No. of Dependents Unknow n NCCI Class Code Wage Rate Day Month # Days Worked/WK Full Pay for Date of Injury? Yes No $ Week Other # Hrs Worked per Day Did Salary Continue? Yes No Time Employee AM Date of Injury Time AM Last Work Date Date Employer Notified Date Disability Began Work or Illness Occurred PM PM Began Employer Contact Name/Phone Number Type of Illness/Injury Part of Body Affected Did Injury/Illness Exposure Occur on Employer'sPremises? Yes Type of Illness/Injury Code Part of Body Affected Code No Department or location where accident or illness exposure occurred All Equipment, Materials, or Chemicals Employee was using when accident or illness exposure occurred. Specific Activity the Employee was engaged in when the accident or illnessexposure occurred. Work Process the Employee Was Engaged in when accident or illnessexposure occurred. How injury or illness/abnormal health condition occurred. Describe the sequence of events and include any objects or substancesthat directly injured the employee or made the employee ill. Cause of Injury Code Date Returned to Work If Fatal, Date of Death Were Safeguards or Safety Equipment Provided? Yes No Were they used? Yes No Physician/Health Care Provider (Name & Address) Hospital (Name &Address) Initial Treatment 0 No Medical Treatment 1Minor: By Employer 2Minor Clinic/Hosp 3Emergency Care 4Hospitalized > 24 hr. Witness to Accident (Name & Phone Number) 5 Future Major Medical/Lost Time Anticipated Date Administrator Notified Date Prepared Preparer's Name & Title Preparer's Phone Number IA-1 (2/95) SEE NEXT PAGE FOR IMPORTANT STATE INFORMATION/SIGNATURE REPRINTED WITH PERMISSION OF IAIABC      Applicable in Alaska A person who willfully makes a false or misleading statement or representation for the purpose of obtaining or denying abenefit or payment is guilty of theft by deception. Applicable in Arkansas Any person or entity who willfully and knowingly makes any material false statement or representation for the purpose of obtaining any benefit or payment, or for the purpose of defeating or wrongfully decreasing any claim for benefit or payment or obtaining or avoiding worker's compensation coverage or avoiding payment of the proper insurance premium (or who aids and abets for either said purpose), under this chapter shall be guilty of a Class D. felony. Applicable in California Any person who makes or causes to be made any knowingly false or fraudulent material statement or materialrepresentation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony. Applicable in Connecticut This form must be completed in its entirety. Any person who intentionally misrepresents or intentionally fails to discloseany material fact related to a claimed injury may be guilty of a felony. Applicable in Delaware and Oklahoma Any person who, knowingly and with intent to injure, defraud, or deceive any Insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. The lack of such a statement shall not constitute adefense against prosecution under this section. *Delaware Statutes Regulation: Del #C Section 913(B) Applicable in Florida Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company orself-insured program, files any statement of claim containing any false or misleading information is guilty of a felony of the third degree. Applicable in Idaho Any person who Knowingly and with the intent to injure, Defraud, or Deceive any Insurance Company, Files a Statement of Claim Containing any False, Incomplete or Misleading information is Guilty of a Felony. Applicable in Indiana A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete,or misleading information commits a felony. Applicable in Kentucky and New York Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any factmaterial thereto, commits a fraudulent insurance act, which is a crime. In New York, such person shall also be subject to acivil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Applicable in Michigan Any person who knowingly and with intent to injure or defraud any insurer submits a claim containing any false,incomplete, or misleading information shall, upon conviction, be subject to imprisonment for up to one year for amisdemeanor conviction or up to ten years for a felony conviction and payment of a fine of up to $5,000.00. Applicable in Minnesota A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. Applicable in Nevada Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement of claim that contains any false,incomplete or misleading information concerning a material fact is guilty of a felony. Applicable in New Hampshire Any person who, with purpose to injure, defraud or deceive any insurance company, files a statement of claim containingany false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as providedin RSA 638:20. Applicable in New Jersey Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Applicable in Ohio Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Applicable in Pennsylvania Any person who knowingly and with intent to injure or defraud any insurer files a claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years or payment of a fine of up to $50,000. Applicable in Utah Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison. EMPLOYEE SIGNATURE IA-1 (2-95)