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EMPLOYER' REPORT S OF INDUSTRIAL INJURY
COMPLETE AND MAIL THIS REPORT WITHIN 10 DAYS FROM NOTICE OF ACCIDENT. FATALITIES MUST BE REPORTED WITHIN 24 HOURS.
Employer must, on this form, notify his insurance carrier of every injury or disease suffered by an employee, fatal or otherwise, which is claimed to arise our of or in the course of employment.

INDUSTRIAL COMMISSION OF ARIZONA P.O. BOX 19070 PHOENIX, ARIZONA 85005-9070
MAIL TO: (CARRIER NAME & ADDRESS)

FOR CARRIER USE ONLY

FOR OSHA PURPOSES ONLY
OSHA Case #: RECORDABLE INJURY NON-RECORDABLE INJURY
2. SOCIAL SECURITY NUMBER

ARIZONA REVISED STATUTES 23-908 & 23-1061 EMPLOYEE
1. LAST NAME FIRST M.I. 3. BIRTH DATE

4. HOME ADDRESS (NUMBER & STREET)

CITY

STATE

ZIP CODE

5. TELEPHONE

6. SEX

o

MALE

o

7. MARITAL STATUS: FEMALE

o

SINGLE

o

MARRIED

o

DIVORCED

o

WIDOWED 10. NATURE OF BUSINESS (MANUFACTURING, ETC.)

EMPLOYER

8. EMPLOYER' NAME S

9. POLICY NUMBER

11. OFFICE ADDRESS (NUMBER & STREET)

CITY

STATE

ZIP CODE

12. TELEPHONE

ACCIDENT

13. DATE OF INJURY OR ILLNESS

14. TIME OF EVENT

15. TIME EMPLOYEE BEGAN WORK A.M.

16. DATE EMPLOYER NOTIFIED OF INJURY P.M.

o
17. LAST DAY OF WORK AFTER INJURY 18. DATE OF RETURN TO WORK 20. CLASS CODE ON PAYROLL REPORT 21. EMPLOYEE' ASSIGNED DEPARTMENT S

o

P.M.

o

A.M.

o

19. EMPLOYEE' OCCUPATION (JOB TITLE) WHEN INJURED S

22. DEPARTMENT NUMBER

23. DID INJURY OCCUR ON EMPLOYER PREMISES?

o
24. ADDRESS OR LOCATION OF ACCIDENT CITY COUNTY

YES

o

NO STATE

ZIP CODE

25. WHAT WAS THE INJURY OR ILLNESS? Tell us the part of the body that was affected and how it was affected; be more specific than " hurt," " pain," or sore." Examples: " strained back" " ; chemical burn, hand" " ; carpal tunnel syndrome."

26. PART OF BODY INJURED

27. FATAL

o

YES

o

28. IF THE EMPLOYEE DIED, WHEN DID THE DEATH OCCUR? DATE OF DEATH NO ADDRESS (STREET, CITY, STATE & ZIP CODE)

29. WAS EMPLOYEE TREATED IN AN EMPERGENCY ROOM? YES NO 30. WAS EMPLOYEE HOSPITALIZED OVERNIGHT AS AN IN-PATIENT? YES NO 31. IF VALIDITY OF CLAIM IS DOUBTED, STATE REASON

NAME OF PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL

o o

o o

IF HOSPITALIZED, HOSPITAL NAME

ADDRESS (STREET, CITY, STATE & ZIP CODE)

CAUSE OF ACCIDENT

32. WHAT HAPPENED? Tell us how the injury occurred. Examples: " When ladder slipped on wet floor, worker fell 20 feet" " ; Worker was sprayed with chlorine when gasket broke during replacement" " ; Worker developed soreness in wrist over time."

33. WHAT OBJECT OR SUBSTANCE DIRECTLY HARMED THE EMPLOYEE? Examples: " concrete floor" " ; chlorine" " ; radial arm saw." If this question does not apply to the incident, leave it blank.

34. WHAT WAS EMPLOYEE DOING JUST BEFORE THE INCIDENT OCCURRED? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. Examples: " climbing a ladder while carrying roofing materials" " ; spraying chlorine from hand sprayer" " ; daily computer key-entry."

35. IF ANOTHER PERSON NOT IN COMPANY EMPLOY CAUSED ACCIDENT, GIVE NAME AND ADDRESS

EMPLOYEE' S WAGE DATA

36. WAS WORKER IN YOUR EMPLOY WHEN INJURED? YES NO

37. HOURS PER DAY EMPLOYEE WORKED

IMPORTANT

FROM IF WORK LOSS IS EXPECTED TO EXCEED SEVEN CALENDAR DAYS, COMPLETE ITEMS 40 THRU 47

o

o

38. WAS EMPLOYEE ON OVERTIME WHEN INJURED? YES NO A.M. P.M. 41. WAS WORKER PAID FOR DAY OF INJURY?

A.M. P.M. THRU 40. DATE OF LAST HIRE

o

o

39. NUMBER OF DAYS PER WEEK USUALLY WORKED

o o

YES

o

NO

IF YES, $

EMPLOYEE COMPANY 42. WAS EMPLOYEE HIRED FOR PERMANENT EMPLOYMENT?

o

43. NUMBER OF MONTHS EMPLOYMENT AVAILABLE DURING THE YEAR

44. GIVE EMPLOYEE' WAGE STATUS AS APPLICABLE S HOUR DAY WEEK MONTH

45. IS EMPLOYEE FURNISHED LODGING

YES VALUE

o

NO

$ PER 46. ACTUAL GROSS EARNINGS OF EMPLOYEE FOR THE 30 CALENDAR DAYS PRECEEDING INJURY (EXAMPLE: IF INJURED APRIL 8, GIVE EARNINGS FROM MARCH 9 THRU APRIL 7) IMPORTANT
IF EMPLOYEE IS PAID OTHER THAN FIXED WEEKLY OR MONTHLY SALARY, COMPLETE ITEMS 48 THRU 55

o

o

o

o

o

BOARD

o

BOTH

$

47. DOES EMPLOYEE CLAIM DEPENDENTS?

o

YES

o

NO

48. IF EMPLOYEE EARNS EXTRA PAY FOR OVERTIME, WHAT IS BASIS OF PAYMENT? PER HOUR

49. NUMBER OF HOURS OVERTIME CONSIDERED NORMAL PER WEEK

50. GROSS WAGES OF EMPLOYEE DURING 12 MONTHS PRECEEDING INJURY

51. IF EMPLOYEE WORKED LESS THAN 12 MONTHS, SHOW GROSS WAGES FROM DATE OF HIRE THROUGH DAY PRIOR TO INJURY FROM 54. WAGE AFTER INCREASE THRU 55. GROSS EARNINGS FROM DATE OF INCREASE THRU DAY PRIOR TO INJURY

FROM THRU 52. DATE OF LAST WAGE INCREASE IF WITHIN 12 MONTHS PRIOR TO INJURY

$
53. WAGE BEFORE INCREASE

$

$
AUTHORIZED SIGNATURE
DATE AUTHORIZED SIGNATURE

$

$
TITLE

NOTE TO EMPLOYER:

1. 2. 3.

Mail one copy to the Industrial Commission within 10 days. Mail one copy to your insurance carrier within 10 days. Keep one copy, for not less than five (5) years, as your supplementary record of injuries required by the Federal Occupational Safety and Health Act of 1970.

The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of
1974, because the Commission' forms, prescribed under the Commission' Rules in existence prior to January 1, 1975, required disclosure of the social security number. The number is used as a means of identifying all the various records s s in the Claims Division or Special Fund pertaining to an individual. The use of social security numbers is made necessary because of the large number of persons who have similar names and birth dates, and whose identities can only be distinguished by the social security number. Form ICA 04-0101 (Rev. 7/01)

THIS FORM APPROVED BY THE INDUSTRIAL COMMISSION OF ARIZONA FOR CARRIER USE