Fill and Sign the Pa Injury Form

MARRIEDSINGLE                                                                                                                                                                                                      EMPLOYEE SOCIAL SECURITY NUMBER COMMONWEALTH OF PENNSYLVANIADEPARTMENT OF LABOR AND INDUSTRYBUREAU OF WORKERS' COMPENSATION1171 S. CAMERON STREET, ROOM 103 HARRISBURG PA 17104-2501(TOLL FREE; 800-482-2383TTY (TOLL FREE) 800-362-4228 EMPLOYER'S REPORT OF OCCUPATIONAL INJURY OR DISEASE 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 FEMALE MONTH DAY YEAR OCCUPATION OR JOB TITLE NCCI CLASS CODE (IF KNOWN) EMPLOYMENT STATUS FT = Full-time SL = SeasonalPT = Part-time VO = Volunteer ZZ = Other EMPLOYER STREET ADDRESS CITY STATE ZIP CODE SIC CODE EMPLOYER FEIN PHONE NUMBER COUNTY FULL PAY FOR DAY OF INJURY? TIME EMPLOYEE BEGAN WORK TIME OF OCCURRENCE YES AM AM NO PM PM LAST DAY WORKED DATE DISABILITY BEGAN 344 1197-1 MONTH DAY YEAR MONTH DAY YEAR DATE EMPLOYER NOTIFIED DATE RETURNED TO WORK MONTH DAY YEAR MONTH DAY YEAR 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 leftcorner and a copy to employee and insurer.LIBC-344 REV 1-01 (OVER)                                                            NO MEDICAL TREATMENTMINOR BY EMPLOYEECLINIC / HOSPITALPANEL PHYSICIANEMPLOYEE PHYSICIANEMERGENCY CAREHOSPITALIZED MORE THAN 24 HOURS                                                                                                                                                                         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 DID INJURY OR ILLNESS OCCURON EMPLOYERS PREMISES? IF OUT OF STATE SPECIFY STATE OF INJURY WERE SAFEGUARDS OR SAFETYEQUIPMENT PROVIDED? WERE SAFEGUARDS OR SAFETYEQUIPMENT USED? YES YES YES NO NO NO 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 IF FATAL, GIVE DATE OF DEATH INITIAL TREATMENT MONTH DAY YEAR PHYSICIAN/HEALTH CARE PROVIDER FIRST NAME: LAST NAME: STREET CITY STATE ZIP POLICY PERIOD FROM: HOSPITAL NAME: STREET MONTH DAY YEAR CITY STATE ZIP POLICY PERIOD TO: POLICY/SELF INSURED NUMBER: MONTH DAY YEAR WITNESS FIRST NAME WITNESS PHONE NUMBER WITNESS LAST NAME PERSON COMPLETING THIS FORM: INSURANCE CARRIER OR THIRD PARTY ADMINISTRATOR (IF SELF-INSURED) NAME: NAME: TITLE: STREET PHONE: CITY STATE ZIP BUREAU CODE: FEIN: DATE PREPARED MONTH DAY YEAR Any individual filing misleading or incomplete information knowingly and with intent todefraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Actand may also be subject to criminal and civil penalties through Pennsylvania Act 165. 344 1197-2