Free First Report of Injury or Illness - Mississippi

MWCC - WORKERS' COMPENSATION - FIRST REPORT OF INJURY OR ILLNESS
EMPLOYER (NAME & ADDRESS INCL ZIP) CARRIER/ADMINISTRATOR CLAIM NUMBER REPORT PURPOSE CODE JURISDICTION JURISDICTION CLAIM NUMBER

INSURED REPORT NUMBER

EMPLOYER'S LOCATION ADDRESS (IF DIFFERENT) SIC CODE EMPLOYER FEIN

LOCATION # PHONE #

CARRIER/CLAIMS ADMINISTRATOR
CARRIER (NAME, ADDRESS & PHONE NO) POLICY PERIOD TO
CHECK IF APPROPRIATE

CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO)

SELF INSURANCE CARRIER FEIN POLICY/SELF-INSURED NUMBER ADMINISTRATOR FEIN

AGENT NAME & CODE NUMBER

EMPLOYEE/WAGE
NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH SOCIAL SECURITY NUMBER DATE HIRED STATE OF HIRE

ADDRESS (INCL ZIP)

SEX MALE (M) FEMALE

MARITAL STATUS UNMARRIED/SINGLE/DIVORCED MARRIED

OCCUPATION/JOB TITLE

(U)
EMPLOYMENT STATUS

(F) UNKNOWN (U)

(M) (S)

PHONE

# OF DEPENDENTS

SEPARATED

NCCI CLASS CODE

UNKNOWN (K) RATE PER: DAY WEEK MONTH OTHER: #DAYS WORKED WEEK FULL PAY FOR DAY OF INJURY? DID SALARY CONTINUE? YES YES NO NO

OCCURRENCE/TREATMENT
TIME EMPLOYEE BEGAN WORK CONTACT NAME/PHONE NUMBER AM PM DATE OF INJURY/ILLNESS TIME OF OCCURRENCE AM LAST WORK DATE PM TYPE OF INJURY/ILLNESS PART OF BODY AFFECTED DATE EMPLOYER NOTIFIED DATE DISABILITY BEGAN

DID INJURY/ILLNESS EXPOSURE OCCUR ON EMPLOYER'S PREMISES? YES NO COUNTY WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

TYPE OF INJURY/ILLNESS CODE

PART OF BODY AFFECTED CODE

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

SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN 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(ED) TO WORK

IF FATAL, GIVE DATE OF DEATH

WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? WERE THEY USED? HOSPITAL (NAME & ADDRESS)

YES YES INITIAL TREATMENT NO MEDICAL TREATMENT (0) MINOR: BY EMPLOYER (1) MINOR CLINIC/HOSP (2) EMERGENCY CARE (3)

NO NO

PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS)

WITNESSES (NAME & PHONE #)

DATE ADMINISTRATOR NOTIFIED

DATE PREPARED

PREPARER'S NAME & TITLE

HOSPITALIZED > 24 HRS (4) FUTURE MAJOR MEDICAL/ LOST TIME ANTICIPATED (5) PHONE NUMBER

IAIABC IA-1 (8/01)

SEE BACK FOR INSTRUCTIONS REPRINTED WITH PERMISSION OF IAIABC