Free Report of Injury (WC-1-EDI) (Fillable and Printable) - Missouri

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION

P.O. BOX 58 JEFFERSON CITY, MO 65102-0058
(To complete form, see attached instructions)

REPORT OF INJURY
EMPLOYER (NAME, ADDRESS, INCL ZIP CODE) CARRIER ADMINISTRATOR CLAIM NUMBER

REPORT PURPOSE CODE

JURISDICTION

JURISDICTION CLAIM NUMBER

GENERAL

INSURED REPORT NUMBER

EMPLOYERS LOCATION ADDRESS (IF DIFFERENT)

LOCATION #

SIC CODE

EMPLOYER FEIN

PHONE #

CARRIER (NAME, ADDRESS & PHONE NO.)

POLICY PERIOD

CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO.)

to CLAIMS ADMIN

CARRIER

CHECK IF APPROPRIATE SELF INSURANCE CARRIER FEIN INSURANCE POLICY NUMBER ADMINISTRATOR FEIN

AGENT NAME & CODE NUMBER

NAME (LAST, FIRST, MIDDLE)

DATE OF BIRTH

SOCIAL SECURITY #

DATE HIRED

STATE OF HIRE

EMPLOYEE

ADDRESS (INCLUDE ZIP)

SEX MALE FEMALE UNKNOWN

MARITAL STATUS UNMARRIED SINGLE DIVORCED MARRIED SEPARATED UNKNOWN

OCCUPATION JOB TITLE

EMPLOYMENT STATUS

PHONE #

# OF DEPENDENTS

NCCI CLASS CODE

WAGE

RATE PER TIME EMPLOYEE BEGAN WORK

DAY WEEK AM PM

MONTH OTHER

# OF DAYS WORKED/WEEK

FULL PAY FOR DAY OF INJURY? DID SALARY CONTINUE?

YES YES

NO NO

DATE OF INJURY / ILLNESS

TIME OF OCCURRENCE

AM PM

LAST WORK DATE

DATE EMPLOYER NOTIFIED DATE DISABILITY BEGAN

CONTACT NAME PHONE NUMBER

TYPE OF INJURY ILLNESS

PART OF BODY AFFECTED

OCCURRENCE

DID INJURY ILLNESS EXPOSURE OCCUR ON EMPLOYER'S PREMISES? YES NO

TYPE OF INJURY/ILLNESS CODE

PART OF BODY AFFECTED CODE

ZIP CODE OF THE LOCATION WHERE THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

WORK PROCESS THE EMPLOYEE WAS ENGAGED IN 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 THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL.

CAUSE OF INJURY CODE

DATE RETURN TO WORK

IF FATAL, GIVE DATE OF DEATH

WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? WERE THEY USED?

YES YES

NO NO

TREATMENT

PHYSICIAN HEALTH CARE PROVIDER (NAME & ADDRESS)

HOSPITAL (NAME & ADDRESS)

INITIAL TREATMENT 0 - NO MEDICAL TREATMENT 1 ­ MINOR: BY EMPLOYER 2 ­ MINOR CLINIC HOSPITAL 3 ­ EMERGENCY CASE 4 ­ HOSPITALIZED > 24 HOURS 5 ­ FUTURE MAJ. MED. LOST TIME ANTICIPATED

OTHERS

WITNESS (NAME & PHONE #)

DATE ADMINISTRATOR NOTIFIED

DATE PREPARED

PREPARER'S NAME & TITLE

PHONE NUMBER

WC-1-EDI (06-06) AI

NOTE > This form constitutes both the original notification of injury and detailed report of injury required by §287.380, RSMo (2000) and rules applicable thereto. An injury that requires immediate first aid, which does not result in further medical treatment or lost time from work, need not be reported to the Division. Employers should report all injuries to their workers' compensation insurance carrier or third-party administrator (TPA) within five days of the date of the injury or within five days of the date on which the injury was reported to the employer by the employee, whichever is later. See §287.380, RSMo. If the employer has been granted selfinsurance authority by the Division pursuant to §287.280, RSMo, and rules applicable thereto, please report all injuries to your TPA or Service Company to enable them to file this report with the Division.

PRINT QUALITY > All reports of injury and supporting documents received by the Division will be processed electronically. All forms submitted to the Division MUST be of clear and legible quality. Handwritten forms will not be accepted. Computer generated forms shall use a minimum type size of 10 points. All documents not meeting the above criteria will be returned.

TO BE ANSWERED ONLY IN CASE OF DEATH
DATE OF DEATH

EMPLOYEE'S DEPENDENTS NAME OF DEPENDENT RELATION TO EMPLOYEE ADDRESS OF DEPENDENT ADDRESS CITY STATE ZIP CODE

WC-1-EDI-2 (06-06) AI

Data Element Table for First Report of Injury ­ Hard Copy and EDI
Data Element IAIABC Data Definition Missouri Notes This is the name the employer does business under followed by the FULL address including mailing address, city, state and zip code. This is the Standard Industrial Classification Code for the employer. SIC/NAICS codes can be found at www.census.gov/epcd/naics02 Mandatory Field M

Employer (Name The name of the employer where the employee was & Address) employed at the time of the injury. Industry Code The code which represents the nature of the employer's business which is contained in the North American Industry Classification System Manual published by the Federal Office of Management and Budget. See implementation note below: The industry code selected should represent the primary nature of the employer's business. If the employer is assigned multiple industry codes, use the code that relates to the specific business operation for which the employee was employed at the time of the injury. The data element may contain an SIC code or NAICS Code. SIC code will be identified with the characters `SC' as the last two characters of the data element. If SC is not present, the code is presumed to be NAICS. Employer FEIN Report Purpose Code (RPC) The FEIN of the employer where the employee was employed at the time of the injury.

M

Must be the primary FEIN for the Employer listed above.

M M

Defines the specific purpose of the report being filed with the The original or Initial First Report of Injury that the employer is state of Missouri. required to file with the Division of Workers' Compensation (Division) through the insurance carrier or third party administrator 00 = Original FROI (TPA) Identifies a specific claim within a claim administrator's claims processing system. The governing body or territory whose statute applies. Number used by the organization adjusting the claim (insurance company, third party administrator, etc.). This must always be Missouri. The injury number assigned by the Division upon receipt of the First Report of Injury with all mandatory information provided. The reporting entity is to leave this field blank. A number used by the insured to identify a specific claim.

Claims Administrator's Number Jurisdiction Jurisdiction Claim Number Insured Report Number

M

M

O

WC-1-EDI-3 (06-06) AI

Data Element Employer's Location Address Insured Location Number Phone Number

IAIABC Data Definition List the physical address of where the employee sustained the accident or illness if that location is different from where the employer wishes to have correspondence sent. A code defined by the insurer/employer, which is used to identify the employer's location of the accident. List a phone number of the employer location where the employee worked at the time of the accident.

Missouri Notes

Mandatory Field O

O O If the employer is individually self-insured, the individual selfinsured employer's name and mailing address would be indicated in this field. The FEIN and Name must match. If the employer is self-insured by a trust, the trust's name would be submitted in this field. M

Carrier (insurer) The name and mailing address of the carrier or self-insured Name & Address entity assuming the employer's financial responsibility for the workers' compensation claim.

Carrier (insurer) FEIN Number Carrier Policy Number

The FEIN of the carrier or self-insured assuming the employer's financial responsibility for the workers' compensation claim(s). The number assigned to the contract/policy for the employer A number assigned by the insurance company, (Not a number or association group. assigned by a TPA) for the specific workers' compensation policy for that employer. Not a required field for Division approved self-insureds.

M

M

Policy Period

List the effective and expiration dates of the contract/policy.

The date that the policy became effective and the date the policy expires or is no longer in effect. No date is required in this field if the injury falls within the Division approved self-insurer's self-insurance period.

M

Self-Insured Indicator

An indicator that identifies the employer as one who retains the risks arising from its operations and bears the financial responsibility. Check box if applicable.

An indicator used for an individually self-insured employer or an employer authorized to self insure through a trust by Missouri Division of Workers' Compensation and is financially responsible for workers' compensation claims. Name and mailing address of the Third Party Administrator (TPA), independent adjuster, contracted to adjust the claim and phone number of the office adjusting the claim. If there is not a TPA, independent adjuster/administrator, contracted to adjust the claim please leave blank.

C

Claim Administrator (TPA) Name & Address

The name and mailing address of the Third Party Administrator (TPA), independent administrator, contracted to adjust the claim on behalf of the carrier or self-insured.

C

WC-1-EDI-4 (06-06) AI

Data Element Claim Administrator (TPA) FEIN Number Agent Name & Code Number Employee Name

IAIABC Data Definition The FEIN of the Third Party Administrator (TPA), independent adjuster/administrator, contracted to adjust the claim on behalf of the carrier or self-insured. List the name and code number of the carrier or claim administrator agent who administers the workers' compensation claims for the employer. The injured worker's legally recognized name which is used on legal documents, employment, Social Security, banking, records, etc. The date the injured worker was born. A number assigned by the Social Security Administration used to identify the employee. The date the injured worker began his/her employment with the employer under which the claim is being filed. If there have been multiple periods of employment, this would be the beginning date of the current employment period. List the state where the employer hired the employee. The mailing address used by the injured worker.

Missouri Notes FEIN number for the company hired as a TPA. Note: If there is no Third Party Administrator, please leave blank.

Mandatory Field C

O

Name to include last, first and middle initial.

M

Employee Date of Birth Social Security Number Date of Hire

Must be a valid date. Can use Missouri Driver's license after 7/1/03. If neither a SSN or MO driver's license is available please call 888-837-6069. Must be valid date.

M M O

State of Hire Employee Address

O The address should not be listed as unknown. Please include the last known address provided by the employee that is on file with the employer. This is an optional field, although if the employer or insurance company has this information, please report it to the Division. This will improve communication between the parties. This will be a numeric field only 5736367777. M

Employee Phone A telephone number where the injured worker can be reached.

O

Gender Code

The code which indicates the sex of the employee. Gender of employee F=Female M=Male U=Unknown

M

Number of Dependents Marital Status Code

The number of dependents as defined by the administrating jurisdiction. The code, which indicates the marital status of the employee. U = Widowed, divorced, single, unmarried, M = Married, S = Separated, K = Unknown

Spouse, minor children or others if known. Required if date of death is entered. Numeric field 0-9.

C O

WC-1-EDI-5 (06-06) AI

Data Element Occupational/ Job Title or Description Employment Status Code NCCI Class Code

IAIABC Data Definition Identifies the primary occupation of the employee at the time of the accident or injurious exposure. Indicate the employee's primary work code status at the time of the injury with the covered employer. A code, which, corresponds to the primary occupation in which the employee was engaged at the time of the accident/injury or injurious exposure. The reported employee's pre-injury wage for the wage period. Implementation Note: This amount may include commission, piecework earnings, and other forms of income converted to a normal scheduled work week, plus the estimated value of lodging, food, laundry and other payments in kind; and concurrent employment earnings, as prejurisdictional requirement.

Missouri Notes

Mandatory Field O

O These codes are provided on the Division Web Site www.dolir.mo.gov/wc/employers MO currently uses NCCI codes. "Gross Wages" includes, in addition to money paid by the employer for services rendered by the employee, the reasonable value of board, rent, housing, lodging or similar advance by the employer, except if it continues to be provided to the employee for the period of disability, it is not included in calculating the average weekly wage. "Wages" also includes gratuity received in the course of employment from individuals other than the employer that are reported for income tax purposes. "Wages" does not include fringe benefits such as retirement, pension, health and welfare, life insurance, training, Social Security or other employee or dependent benefit plan provided by the employer. See Special Notes #1 M M

Wage

Wage Period Number of Days Worked Full Wages Paid for the Date of Injury Indicator Salary Continued Indicator Time Employee Began Work

A code indicating the time period during which the wage was Please use the weekly wage rate paid to the employee. earned. The number of the employee's regularly scheduled workdays per week. Indicates whether full wages for the date of the accident/injury or illness were paid by the employer. The employer has paid or is paying the employee's salary in lieu of compensation during an absence caused by a workrelated injury. Time at which the employee began work on the day of the accident/injury or illness. Did the employer continue to pay salary to the employee after the injury? N=No Y=Yes

M O O

O

O

WC-1-EDI-6 (06-06) AI

Data Element Date of Injury/Illness

IAIABC Data Definition

Missouri Notes

Mandatory Field M

For traumatic injury, the date on which the accident Date that injury/illness occurred or became known to employee; occurred. For occupational disease or cumulative injury, the whichever is later. date of injury is the date of last injurious exposure to the cause or substance creating the condition, unless otherwise defined by statute. The time at which the accident occurred. To the extent that the time of the occurrence of the accident/injury is available, you should provide it to the Division. Please indicate a.m. or p.m. Must be valid date.

Time of Occurrence Date Last Day Worked Date Employer Notified Date Disability Began

O

The last paid workday prior to the initial date of disability as defined by jurisdiction. The date that the injury was reported to a representative of the employer. The first day on which the employee originally lost time from work due to the occupational injury or disease or as otherwise defined by jurisdiction.

O M

Date of disability must be greater than Date of Injury. First date employee starts losing time from work after the date of injury. This is the day after the date of injury or the first day of work missed, if later. The three-day waiting period is calculated from the first date of lost time and the lost time does not need to be consecutive days. See Special Note #2

C

Contact Name & Phone Number Type of Injury/Illness Part of Body Affected Employer Premises Indicator Type of Injury/Illness Code Part of Body Affected Code

List the name and phone number for a representative of the employer. List the type of injury/illness sustained by the employee. List the part of body to which the employee sustained injury. An indicator to denote whether the accident occurred at the employer's address provided. The code, which corresponds to the nature of the injury sustained by the employee. The code, which corresponds to the part of the body to which the employee sustained injury. If the injury/illness occurred on the employer's property indicate "YES." If it occurred elsewhere indicate "NO." A list of codes with description of each code is available at www.dolir.mo.gov/wc/employers/definitions.doc (Sprain, strain, occupational disease, hernia, amputation, etc.) Choose from the list of code numbers, which corresponds with the part of body injured. A list of codes with a description of each code is available at www.dolir.mo.gov/wc/employers/definitions.doc

C O O M

M

M

WC-1-EDI-7 (06-06) AI

Data Element Zip Code of the Location Where Accident or Illness Exposure Occurred All Equipment Using Specific Activity Engaged In Work Process Engaged In

IAIABC Data Definition The zip (postal code) that corresponds to the location where the injury occurred.

Missouri Notes The code is required to assist with docket setting if needed.

Mandatory Field M

List all the equipment; materials or chemicals the employee was using at the time of the accident/injury or illness exposure occurred. Describe the specific activity that the employee was doing at the time the accident/injury or illness exposure occurred. Describe the work process the employee was doing when the accident/injury or illness exposure occurred.

O

O O M

How the Injury or A free form description of how the accident occurred and the Describe how the injury/illness occurred. Please include the Illness Occurred resulting injuries. events that led to the injury/illness and any objects or substances that directly injured the employee or made the employee ill. Maximum of 150 characters, including spaces. For example: Employee was on ladder putting away product, fell on chemical barrel breaking lower arm; arm lacerations; exposed to chemical liquid and fumes (141 characters). Cause of Injury Code The code which corresponds to the cause of injury. Choose from the list of code numbers, which corresponds with the cause of the injury. A list of codes with a description of each code is available at www.dolir.mo.gov/wc/employers/definitions.doc (Struck by, fell, auto accident, exposure, etc.) Must be a valid date. Must be entered if employee lost days of work and returned to work before first report of injury is filed.

M

Date Returned to The first date on which the employee returned to work Work following the injury. See special note * Employee Date of Death Safeguards The date the injured worker died. Indicate whether safeguards or safety equipment was provided by checking "Yes" or "No."

C

Must be a valid date.

C O O O

Were They Used Indicate whether the safeguards or safety equipment was used by the employee by checking "Yes" or "No." Physician/Health List the name and address of the physician or health care Care Provider provider who provided initial medical treatment to the injured employee after the accident/injury or illness.

WC-1-EDI-8 (06-06) AI

Data Element Hospital Initial Treatment

IAIABC Data Definition List the name and address of the hospital where the employee received initial medical treatment. A code used to identify the extent of medical treatment received by the employee immediately following the accident. 0= No medical treatment 1= Minor on-site remedies by employer medical staff 2= Minor clinic/hospital medical remedies and diagnostic testing 3= Emergency evaluation, diagnostic testing, and medical procedures 4= Hospitalization > 24 hours 5= Future major medical/lost time anticipated **Please see attached special notes for Missouri.

Missouri Notes

Mandatory Field O

First Aid includes the administration of immediate and temporary medical aid to the employee that a lay person may provide, such as the application of Band-Aid to treat a minor scratch or the removal of a splinter that would not result in the need for a referral to a doctor or other health care professional for additional medical treatment. The on-site company nurse or physician may be the individual that provides the first aid. If the company nurse or physician provides service beyond first aid, then the injury must be reported even if the treatment occurs on-site. See Special Notes # 3 & 4

M

Witness

List the name and address of all witnesses who were present when the employee sustained the accident/injury or illness.

O

Date Reported to The date the claim administrator who is processing the claim Claims received notice of the loss or occurrence. Administrator Date Prepared List the date that the representative for the claims administrator prepared this report of injury.

M

O C C

Preparer's Name List the name and title of the claims administrator's and Title representative who prepared this report of injury. Phone Number List the phone number of the representative preparing this report of injury.

M ­ Mandatory Error ­ Cases missing mandatory information will NOT be accepted by the Missouri Division of Workers' Compensation system. C ­ Conditional ­ Data Elements with Conditional errors indicate a value is required based on another Data Element or pre-existing condition. Examples: When a death case is reported then the death date would be required. If the employee has returned to work prior to the report being filed, the date of return to work would be entered. O ­ Optional ­ Data Elements identified as Optional may be entered but are not required.

WC-1-EDI-9 (06-06) AI

Special Notes 1) Report the wage information as the average weekly wage (AWW) of the employee. These rules apply for calculating the average weekly wage. a) b) c) d) If the employee's wage is fixed by the year, the AWW is the yearly wage divided by 52; If the employee's wage is fixed by the month, the AWW is the monthly wage multiplied by 12 and divided by 52; If the employee's wage is fixed by the week, that amount is the AWW; If the employee's wages are fixed by the day, hour or output, the numerator is the actual gross wages earned by the employee in the last thirteen calendar weeks immediately preceding the week in which the injury occurred; and the denominator is 13 to calculate the AWW. i) The formula is: Actual gross wages earned in prior 13 weeks/13=AWW. For example, the employee's hourly wage is $9.00/hour. The overtime

rate is $13.50/hour. The employee works 40 hours per week at $9.00 an hour plus occasional overtime. Employee worked overtime of 44 hours in the 13-week period immediately preceding the week of the injury. The employer has employed the employee for 2 years.

The gross wages are $9.00 X 40 hours X 13 weeks = $4,680. You also need to include the overtime 44 hours. Therefore, $13.50 X 44 hours = $594. The total wages are $4,680 plus $594 = $5,274. The AWW is $5,274/13=$405.69.
ii) If the employee misses nonconsecutive workdays during the 13-week period in multiples of 5 and receives no compensation, such as sick or other leave, those days shall be subtracted from the denominator. For example: if the employee misses 5 days, one week is subtracted from 13 and the

denominator becomes 12; if the employee misses 10 days, two week are subtracted from 13 and the denominator becomes 11; and so on.
iii) iv) Partial weeks of time missed by the employee do not count to change the denominator. For example: if the employee misses 4 days, the denominator is 13; if the employee misses 6 days, one week is subtracted from 13 and the denominator becomes 12; and so on.

employer 8 weeks prior to the week of the injury. The employee was paid $9.00 per hour and worked 40 hours per week. The employee worked 13 hours of overtime. The overtime rate is $13.50. The gross wages are $9.00 X 40 hours X 8 weeks plus $13.50 X 13 hours = $3,055.50. The AWW is $3,055.50/8=$381.94.
e) If the employee works less than two weeks the AWW shall be equivalent to the AWW for the same or similar employment. However, if the employer has agreed to a certain hourly wage, then the hourly wage agreed upon multiplied by the number of weekly hours scheduled shall be the employee's AWW. 2)

If the employee works less than 13 weeks but more than 2 weeks, the AWW is the same formula with the numerator as the gross wages calculated for the number of weeks of employment and the denominator is the number of weeks of employment. For example, the employee worked for the

When the Date Returned to Work is more than three days from the Date Disability Began, the workers' compensation case will be considered an indemnity case. You will receive a request for the cost of medical treatment, the date returned to work, and the total amount of temporary total disability benefits paid to the employee. When Initial Treatment Code is reported as equal to 00, 01 or 02, the case will be considered as a medical only case. If the time period between the Date Disability Began and the Date Returned to Work is three days or less, the case will be classified as a medical only case. You will receive a request for the cost of medical treatment and the date returned to work, if not supplied. After all required information has been filed and there is no further activity on a case for six months, the case may be administratively closed. When the Initial Treatment Code is reported as equal to 03, 04 or 05, the case will be considered as an indemnity case. You will receive a request for the cost of medical treatment, the date returned to work, and the total amount of temporary total disability benefits paid to the employee.

3)

WC-1-EDI-10 (06-06) AI

4)

The following are examples of First Aid treatment. a) b) c) d) e) f) g) h) Use of non-prescription medication at non-prescription strength. Cleaning, flushing or soaking wounds on the surface of the skin. Using wound coverings such as bandages, Band-Aids, gauze pads, etc. or using butterfly bandages or Steri-Strips. (Other wound closing devises such as sutures, staples, glues, etc. are considered medical treatment.) Use of any non-rigid means of support such as an elastic bandage, wrap, or non-rigid belt. (The use of devices with rigid stays or other systems designed to immobilized body parts is considered medical treatment.) Use of temporary immobilization devices (e.g., splints, slings, neck collars, etc.) while transporting an accident victim. Removing splinters or foreign material from areas other than the eye by irrigation, tweezers, cotton swabs, or other simple means. Use of finger guards. Drinking of fluids for relief of heat stress.

WC-1-EDI-11 (06-06) AI