Fill and Sign the Montana First Report Injury Form

First Report Adjuster Date Stamp of Injury or Occupational Disease Montana Department of Labor and Industry PO Box 8011 Helena, MT 59604-8011 Worker L AST N AME       F IRST N AME       M.I.   D ATE OF B IRTH       S OCIAL S ECURITY N UMBER       M AILING A DDRESS       C ITY       S TATE       P OSTAL C ODE       P HONE N UMBER       E DUCATION L ESS T HAN H IGH S CHOOL GED OR H IGH S CHOOL D IPLOMA B EYOND H IGH S CHOOL G ENDER M ALE F EMALE U NKNOWN M ARITAL S TATUS M ARRIED S EPARATED W IDOWED , D IVORCED , S INGLE , U NMARRIED U NKNOWN N UMBER OF D EPENDANTS     Wages D ATE H IRED       G ROSS EARNINGS FOR FOUR PAY PERIODS PRECEDING THE INJURY D ATE /A MOUNT       /       D ATE /A MOUNT       /       D ATE /A MOUNT       /       D ATE /A MOUNT       /       E MPLOYMENT S TATUS F ULL T IME P ART T IME S EASONAL P IECE W ORKER V OLUNTEER O THER N UMBER OF DAYS WORKED PER WEEK   W AGE       W AGE P ERIOD H OUR W EEK MONTH D AY B I - WEEKLY I N ADDITION TO G ROSS EARNINGS CITED ABOVE WORKER RECEIVED E STIMATED VALUE IF ANY R OOM & B OARD O VERTIME B ONUS C OMMISSIONS O THER       T IME E MPLOYEE BEGAN WORK       W ORKED NEXT SCHEDULED SHIFT Y ES N O O FF WORK MORE THAN 4 WORK DAYS Y ES N O N OT S URE D ATE L AST W ORKED       D ATE OF R ETURN TO WORK       F ULL WAGES PAID FOR DATE OF I NJURY YES N O S ALARY C ONTINUED Y ES N O Accident Description J OB T ITLE       D ESCRIPTION OF A CCIDENT       C AUSE OF I NJURY       C AUSE C ODE     P ART OF B ODY       P ART C ODE     N ATURE OF I NJURY       N ATURE C ODE     D ATE OF I NJURY       T IME OF I NJURY       D ATE DISABILITY BEGAN       D ATE OF D EATH       N AMES OF WITNESSES 1)       2)       3)       A CCIDENT ON EMPLOYER ’ S PREMISES Y ES N O A CCIDENT ADDRESS OR LOCATION C ITY       S TATE       P OSTAL CODE       D ATE EMPLOYER NOTIFIED       A CCIDENT R EPORTED TO       S AFETY EQUIPMENT PROVIDED Y ES N O S AFETY E QUIPMENT USED Y ES N O Medical A TTENDING P HYSICIAN ’ S N AME       A DDRESS       S TATE       P OSTAL C ODE       P HONE NUMBER       H OSPITAL NAME       A DDRESS       S TATE       P OSTAL C ODE       P HONE NUMBER       T YPE OF INITIAL MEDICAL TREATMENT RECEIVED N O T REATMENT E MERGENCY ROOM /U RGENT C ARE T REATMENT ON - SITE BY EMPLOYER OR MEDICAL S TAFF C LINIC /D R . O FFICE H OSPITAL >24 H OURS Signature “This is my claim for workers’ compensation benefits due to the on-the-job injury, occupational disease, or death of the above named worker. I understand that signing this claim for compensation authorizes the release to the workers’ compensation insurer (and its agents) and to the Montana Uninsured Employers’ Fund of: Social Security records; rehabilitation records; and all health care information (medical records, pursuant to HIPAA, Public Law 104-191, 42 USC section 1301, et. seq., and section 39-71-604, MCA), that are directly relevant to the claimed injury, disease, or death. I also understand that if I obtain or exert unauthorized control over workers’ compensation benefits to which I am not entitled, I may be prosecuted for theft.” Signature of Injured Worker or Benefiiarr Date Employer E MPLOYER NAME       D OING B USINESS AS       F EDERAL E MPLOYER I DENTIFICATION N UMBER (T AX ID)       M AILING A DDRESS       C ITY       S TATE       P OSTAL C ODE       P HONE N UMBER       L OCATION OF OPERATION , IF DIFFERENT FROM MAILING ADDRESS       N ATURE OF B USINESS NAICS C ODE       S ELF -I NSURED ? Y ES N O E MPLOYER IS A S OLE P ROPRIETORSHIP P ARTNERSHIP C ORPORATION L IMITED L IABILITY C OMPANY I NJURED WORKER IS A S OLE P ROPRIETORSHIP P ARTNERSHIP C ORPORATION L IMITED L IABILITY C OMPANY A MEMBER OF THE EMPLOYER ’ S ( SOLE PROPRIETOR OR PARTNER ) FAMILY LIVING IN THE EMPLOYER ’ S HOUSEHOLD D O YOU HAVE ANY REASON TO QUESTION THIS ACCIDENT ? Y ES N O I F YES , PLEASE EXPLAIN FULLY . U SE SEPARATE SHEET IF YOU NEED ADDITIONAL SPACE       W AS WORKER INJURED WHILE IN YOUR EMPLOY YES NO Prepared Br       Offiiial Titl e       Phone Number       Date       P AYROLL C LASSIFICATION C ODE UNDER WHICH YOU REPORT E MPLOYEE ’ S WAGES         A UTHORIZED E MPLOYER ’ S S IGNATURE _______________________________________________ D ATE __________________________ InsurerOSHA Log Case # C LAIM A DMINISTRATOR C LAIM N UMBER       D ATE REPORTED TO C LAIM A DMINISTRATOR       T HE ABOVE INFORMATION IS CORRECT WITH THE FOLLOWING EXCEPTIONS (A TTACH EXTRA SHEETS IF BOX AT RIGHT IS CHECKED ) C LAIM A DMINISTRATOR ’ S N AME       C LAIM A DMINISTRATOR A DDRESS       C LAIM A DMINISTRATOR FEIN       I NSURER N AME       I NSURER FEIN       P OLICY N UMBER       P OLICY E FFECTIVE DATE       P OLICY E XPIRATION D ATE       ERD – 991 (Rev. 08/2014 DE) DLI-ERD-WCC041