Fill and Sign the Report Injury 497334794 Form

REPORT OF OCCUPATIONAL INJURY OR ILLNESS Employee: Answer Questions 1-17, immediately mail report 1. Last Name First Name Initial                   2. Telephone Number       3. Date of Birth       4. Sex Male Female 5. Social Security Number       -       -       6. Mailing Address:       7. Residence Address:       8. City, Town, Village where injury occurred:       9. Date and hour of last exposure to injury or disease:       10. On employer’s premises? Yes No 11. Full Name and Address of Attending Physician:       12. Hospitalized as In-Patient: Yes No 13. Name and Address of Hospital:       14. Type of Injury or illness and part of body injured:       Left Right 15. Describe how the injury or illness happened:       16. Employee’s Signature: ______________________________________ 17. Date Signed:       Employer: Answer Questions 18-49 18. Employer’s Name and Telephone Number:       19. Employer’s Address( if different from mailing):       20. Employer’s Mailing Address:       21. Name of Insurer:       22. Full Name and Address of Adjusting Company:       23. Mailing Address of Adjusting Company:       24. Date Employer First Knew Injury or Illness was Work Related:       25.Time Employee Left Work:       26. Time Lost Beyond Date of Injury or Illness:       27. Date Returned to Work:       28. Death Yes No Date:       29. Location Where Injury or Illness Took Place:       30. Employee’s Occupation:       31. Date Hired by Employer:       32. Earnings Calculated By: Hr. Day Output Wk. Mo. Year 33. Rate of Pay:       34. Days Employee Works per Week: 3 or Less 4 5 6 7 35. Name Scheduled Days Off:       36.Work Day Began:       37. Was Employee Paid for Day of Injury or Illness? Yes No 38. Federal EIN Number:       39. Give Details of How Injury or Illness Happened:       40. Was Injury or Illness Caused by Failure of a Machine or Product? Yes No 41. Were Mechanical Guards or Other Safeguards Provided? Yes No 42. Name Machine, Substance, or Object which Injured Employee:       43. If Mechanical, Specify Which Part:       44. Names and Addresses of Witnesses:       45. If the Injury Was Caused by Anyone Besides Employee, Give Name and Address:       46. Dependents (name and address in case of death):       47. If you Doubt Validity of Injury or Illness, Please State Why:       48. Signature of Authorized Employer Representative: ______________________________________________________________ 48. Title:       49. Date Signed: