Fill and Sign the Workers Compensationfirst Report of Injury or Illness Njcrib Form

WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS General Employer (Name & Address incl. zip) Carrier/Administrator Claim Number Report Purpose Code Jurisdiction Jurisdiction Claim No. Insured Report No. Employer’s Location Address (if different) Location No. NAICS Code Employer FEIN Phone No. Carrier/Claims Admin 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 Employee Legal Name (Last, First, Middle) Birth Date Social Security Number Date Hired State of Hire Address (Incl. Zip) Sex Marital Status Occupation/Job Title Male Unmarried/ Single/Div. Female Married Employment Status Unknown Separated Phone No. of Dependents Unknown 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 Occurrence Time Employee Began Work AM Date of Injury or Illness Time Occurred AM Last Work Date Date Employer Notified Date Disability Began PM PM Employer Contact Name/Phone Number Type of Illness/Injury Part of Body Affected Did Injury/Illness Exposure Occur on Employer’s Premises? Yes ype 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 Using upon Occurrence Specific Activity Employee Engaged in at Time of Occurrence Work Process the Employee Was Engaged in at Time of Occurr ence How injury or illness/abnormal health condition occurred. Des cribe the sequence of events and include any objects or substances that 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 Treatment Physician/Health Care Provider (Name & Address) Hospital (Name & Address) Initial Treatment 0 No Medical Treatment 1 Minor: By Employer 2 Minor Clinic/Hosp 3 Emergency Care 4 Hospitalized – 24 hr. Other Signature of Injured Employee, or Signature on File, Date Witness to Accident (Name & Phone Number) 5 Anticipated Major Med/Lost Time Date Administrator Notified Date Prepared Preparer’s Name & Title Preparer’s Phone Number Filing this report is not an admission of liability. This report shall not be evidence of any fact stated herein in any proceeding in respect of the injury, illness or death on account of which this report is made. Idaho Industrial Commis sion, P.O. Box 83720, Boise, ID 83720-0041 IC Form IA- 1 ( 08/2013 )