WORKERS COMPENSATION FIRST REPORT OF INJURY OR ILLNESS
Carrier/Administrator Claim Number Jurisdiction Jurisdiction Claim Number Report Purpose Code
Employer (Name & Address incl. zip)
Insured Report Number Employer's Location Address (if different) Location No.
Carrier (Name, Address & Phone Number) Carrier/Claims Admin
Policy Period To Check if self insured
Claims Admin (Name, Address & Phone Number)
Carrier FEIN Agent Name & Code Number Legal Name (Last, First, Middle) Address (Incl. Zip)
Policy Number or Self-Insured Number
Date of Birth Sex Male
Social Security Number Marital Status Unmarried/ Single/Div. Married Separated Unknown
Date Hired Occupation/Job Title
State of Hire
Female Unknown Phone No. of Dependents
Employment Status NCCI Class Code
Day Week AM PM Date of Injury or Illness
Month Other Time Occurred
# Days Worked/WK # Hrs Worked per Day
Full Pay for Date of Injury? Did Salary Continue? Date Employer Notified
Time Employee Began Work
Last Work Date
Date Disability Began
Employer Contact Name/Phone Number Did Injury/Illness Exposure Occur on Employer's Premises? Occurrence Yes No
Type of Illness/Injury Type of Illness/Injury Code
Part of Body Affected Part of Body Affected Code
Department or location where accident or illness exposure occurred
All Equipment, Materials, or Chemicals Employee was using when accident or illness exposure occurred. Work Process the Employee Was Engaged in when accident or illness exposure occurred. Cause of Injury Code
Specific Activity the Employee was engaged in when the 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. Date Returned to Work If Fatal, Date of Death
Physician/Health Care Provider (Name & Address) Treatment
Witness to Accident (Name & Phone Number) Other
Were Safeguards or Safety Equipment Provided? Yes No Were they used? Yes No Hospital (Name & Address) Initial Treatment 0 No Medical Treatment 1 Minor: By Employer 2 Minor Clinic/Hosp 3 Emergency Care 4 Hospitalized > 24 hr. 5 Future Major Medical/Lost Time Anticipated Preparer's Name & Title Preparer's Phone Number
Date Administrator Notified
SEE NEXT PAGE FOR IMPORTANT STATE INFORMATION/SIGNATURE REPRINTED WITH PERMISSION OF IAIABC
Applicable in Alaska
A person who willfully makes a false or misleading statement or representation for the purpose of obtaining or denying a benefit or payment is guilty of theft by deception.
Applicable in Arkansas
Any person or entity who willfully and knowingly makes any material false statement or representation for the purpose of obtaining any benefit or payment, or for the purpose of defeating or wrongfully decreasing any claim for benefit or payment or obtaining or avoiding worker's compensation coverage or avoiding payment of the proper insurance premium (or who aids and abets for either said purpose), under this chapter shall be guilty of a Class D. felony.
Applicable in California
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony.
Applicable in Connecticut
This form must be completed in its entirety. Any person who intentionally misrepresents or intentionally fails to disclose any material fact related to a claimed injury may be guilty of a felony.
Applicable in Delaware and Oklahoma
Any person who, knowingly and with intent to injure, defraud, or deceive any Insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. The lack of such a statement shall not constitute a defense against prosecution under this section. *Delaware Statutes Regulation: Del #C Section 913(B)
Applicable in Florida
Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company or self-insured program, files any statement of claim containing any false or misleading information is guilty of a felony of the third degree.
Applicable in Idaho
Any person who Knowingly and with the intent to injure, Defraud, or Deceive any Insurance Company, Files a Statement of Claim Containing any False, Incomplete or Misleading information is Guilty of a Felony.
Applicable in Indiana
A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.
Applicable in Kentucky and New York
Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. In New York, such person shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Applicable in Michigan
Any person who knowingly and with intent to injure or defraud any insurer submits a claim containing any false, incomplete, or misleading information shall, upon conviction, be subject to imprisonment for up to one year for a misdemeanor conviction or up to ten years for a felony conviction and payment of a fine of up to $5,000.00.
Applicable in Minnesota
A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
Applicable in Nevada
Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete or misleading information concerning a material fact is guilty of a felony.
Applicable in New Hampshire
Any person who, with purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.
Applicable in New Jersey
Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
Applicable in Ohio
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Any person who knowingly and with intent to injure or defraud any insurer files a claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years or payment of a fine of up to $50,000.
Applicable in Pennsylvania
Applicable in Utah
Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison. EMPLOYEE SIGNATURE: IA-1 (2-95)