Free May 10, 1999 - Idaho

File Size: 348.8 kB
Pages: 1
Date: March 24, 2008
File Format: PDF
State: Idaho
Category: Workers Compensation
Author: Kim Day
Word Count: 415 Words, 2,695 Characters
Page Size: Letter (8 1/2" x 11")

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Employer (Name & Address incl. zip) Carrier/Administrator Claim Number Jurisdiction General Jurisdiction Claim No. Report Purpose Code

Insured Report No. Employer's Location Address (if different) Location No.

Sic Code

Employer FEIN

Phone 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

Administrator FEIN

Birth Date Sex Male

Social Security Number Marital Status Unmarried/ Single/Div. Married Separated Unknown

Date Hired Occupation/Job Title

State of Hire



Female Unknown No. of Dependents

Employment Status NCCI Class Code

Wage Rate

Time Employee Began Work AM PM

Day Week 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

Yes Yes Date Disability Began

No No


Last Work Date

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 Using upon Occurrence

Specific Activity Employee Engaged in at Time of Occurrence

Work Process the Employee Was Engaged in at Time of Occurrence Cause of Injury Code Yes Yes Initial Treatment No Medical Treatment Minor: By Employer Minor Clinic/Hosp Emergency Care Hospitalized 24 hr. Anticipated Major Med/Lost Time N o N o

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 Were Safeguards or Safety Equipment Provided? Were they used? Physician/Health Care Provider (Name & Address) Treatment Hospital (Name & Address) 0 1 2 3 4 5


Signature of Injured Employee, or Signature on File, Date Date Administrator Notified Date Prepared

Witness to Accident (Name & Phone Number)

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 Commission, P.O. Box 83720, Boise, ID 83720-0041 IC Form IA-1 (2/98)