Fill and Sign the Workers and Physicians Report of Injury Form

YESNOYESNOYESNOYESNO IF YES, $ YESNOYESNO OSHA Case #: RECORDABLE INJURY NON-RECORDABLE INJURY MALEFEMALESINGLEMARRIEDDIVORCEDWIDOWED A.M.P. M.A.M.P. M. YES    YESNO YES   LODGINGBOTH     NOEMPLOYER'S REPORT OF INDUSTRIAL INJURY INDUSTRIAL COMMISSION OF ARIZONA P.O. BOX 19070 PHOENIX, ARIZONA 85005-9070 FOR CARRIER USE ONLY COMPLETE AND MAIL THIS REPORT WITHIN 10 DAYS FROM NOTICE OF ACCIDENT. FATALITIES MUST BE REPORTED WITHIN 24 HOURS. FOR OSHA PURPOSES ONLY MAILTO : (CARRIER NAME &ADDRESS) Employer must, on this form, notify his insurance carrier of every injury or disease suffered by an employee, fatal or otherwise, which is claimed to arise our of or in the course of employment. ARIZONA REVISED STATUTES 23-908 & 23-1061 EMPLOYEE1. LAST NAMEFIRSTM. 1.2. SOCIAL SECURITY NUMBER - 3. BIRTH DATE 4. HOME ADDRESS (NUMBER& STREET) CITYSTATEZIP CODE5. TELEPHONE7. MARITAL STATUS SEXEMPLOYER8. EMPLOYER'S NAME 9. POLICY NUMBER 10. NATURE OF BUSINESS (MANUFACTURING ETC.) 11. OFFICE ADDRESS (NUMBER& STREET) CITYSTATEZIP CODE12. TELEPHONEACCIDENT13. DATE OF INJURY OR ILLNESS14. TIME OF EVENT15. TIME EMPLOYEE BEGAN WORK 16. DATE EMPLOYER NOTIFIED OF INJURY 17. LAST DAY OF WORK AFTER INJURY18. DATE OF RETURN TO WORK19. EMPLOYEE'S OCCUPATION (JOB TITLE) WHEN INJURED20. CLASS CODE ON PAYROLL REPORT21. EMPLOYEE'S ASSIGNED DEPARTMENT22. DEPARTMENT NUMBER23. DID INJURY OCCUR ON EMPLOYER PREMISES' 24. ADDRESS OR LOCATION OF ACCIDENTCITYCOUNTYSTATEZIP CODE25. WHAT WAS THE INJURY OR ILLNESS? Tell us the part of the body that was affected and how it was affected; be more specific than ''hurt,'' ''pain,'' or sore.'' Examples: ''strained back''; ''chemical burn, hand''; ''carpal tunnel syndrome." 26. PART OF BODY INJURED 27. FATAL28. IF THE EMPLOYEE DIED, WHEN DID THE DEATH OCCUR? DATE OF DEATH29. WAS EMPLOYEE TREATED IN AN EMERGENCY NAME OF PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL ADDRESS (STREET, CITY, STATE & ZIP CODE) ROOM?30. WAS EMPLOYEE HOSPITALIZED OVERNIGHT AS AN IN-PATIENT?IF HOSPITALIZED, HOSPITAL NAME ADDRESS (STREET, CITY, STATE &ZIP CODE)31. IF VALIDITY OF CLAIM IS DOUBTED, STATE REASON CAUSE OF ACCIDENT32. WHAT HAPPENED ? Tell us how the injury occurred. Examples: ''When ladder slipped on wet floor, worker fell 20 feet''; ''Worker was sprayed with chlorine when gasket broke during replacement''; Worker developed soreness in wrist ever time.'' 33. WHAT OBJECTOR SUBSTANCE DIRECTLY HARMED THE EMPLOYEE? Examples: ''concrete floor''; ''chlorine''; ''radial arm saw.'' If this question does not apply to the incident, leave it blank, 34. WHAT WAS EMPLOYEE DOING JUST BEFORE THE INCIDENT OCCURRED? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. Examples: ''climbing a ladder while carrying roofing materials''; ''spraying chlorine from hand sprayer''; ''daily computer key-entry.'' 35. IF ANOTHER PERSON NOT IN COMPANY EMPLOY CAUSED ACCIDENT, GIVE NAME AND ADDRESS EMPLOYEE'S36. WAS WORKER IN YOUR EMPLOY 37. HOURS PER DAY EMPLOYEE WORKED 38. WAS EMPLOYEE ON OVERTIME 39. NUMBER OF DAYS PER WEEK WHEN INJURED' WHEN INJURED? USUALLY WORKED WAGE DATA NOFROMA. M. P.M. THRU A. M. P. M. EMPLOYEECOMPANYIF WORK LOSS IS EXPECTED TO EXCEED SEVEN CALENDAR DAYS, COMPLETE ITEMS 40 THRU 47 40. DATE OF LAST HIRE 41. WAS WORKER PAID FOR DAY OF INJURY' IMPORTANT42. WAS EMPLOYEE HIRED FOR PERMANENTEMPLOYMENT?43. NUMBER OF MONTHS EMPLOYMENTAVAILABLE DURING THE YEAR 44. GIVE EMPLOYEE'S WAGE STATUS AS APPLICABLE HOUR DAY WEEK MONTH 45. IS EMPLOYEE FURNISHEDVALUE$PERBOARD$46. ACTUAL GROSS EARNINGS OF EMPLOYEE FOR THE 30 CALENDAR DAYS PRECEDING INJURY (EXAMPLE: IF INJURED APRIL 8, GIVE EARNINGS FROM MARCH 9 THRU APRIL 7) 47. DOES EMPLOYEE CLAIM DEPENDENTS? IF EMPLOYEE IS PAID OTHER THAN FIXED WEEKLY OR MONTHLY SALARY, COMPLETE ITEMS 48 THRU 55 48. IF EMPLOYEE EARNS EXTRA PAY FOR OVERTIME, WHAT IS BASIS OFIMPORTANTPAYMENT?49. NUMBER OF HOURS OVERTIME CONSIDERED NORMAL PER WEEK PER HOUR 50. GROSS WAGES OF EMPLOYEE DURING 12 MONTHS PRECEDING INJURY 51. IF EMPLOYEE WORKED LESS THAN 12 MONTHS, SHOW GROSS WAGES FROM DATE OF HIRE THROUGH DAY PRIOR TO INJURY $FROMTHRUFROMTHRU$52. DATE OF LAST WAGE INCREASE IFWITHIN 12 MONTHS PRIOR TO INJURY 53. WAGE BEFORE INCREASE 54. WAGE AFTER INCREASE 55. GROSS EARNINGS FROM DATE OF INCREASE THRU DAY PRIOR TO INJURY $$$AUTHORIZEDDATEAUTHORIZED SIGNATURE TITLESIGNATURENOTE TO EMPLOYER 1 . Mail one copy to the Industrial Commission within 10 days. 2. Mail one copy to your insurance carrier within 10 days. 3. Keep one copy, for not less than five (5) years, as your supplementary record of injuries required by the Federal Occupational Safety and Health Act of 1970. * The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, because the Commission's forms, prescribed under the Commission's Rules in existence prior to January 1, 1975, required disclosure of the social security number. The number is used as a means of identifying all the various records in the Claims Division or Special Fund pertaining to an individual. The use of social security numbers is made necessary because of the large number of persons who have similar names and birth dates, and whose identities can only be distinguished by the social security number. Form ICA 04-01 01 (Rev. 7/01) THIS FORM APPROVED BY THE INDUSTRIAL COMMISSION OF ARIZONA FOR CARRIER USE