Preparer InformationPreparer's Name First Last Preparer's PhonePreparer's TitleDate Prepared MM slash DD slash YYYY Preparer's Email Is this claim for reporting purposes only? Yes NoDid injury occur more than 3 days ago? Yes NoEmployer InformationEmployer NameAddressCityStateZipPhoneEmployee InformationFirst NameLast NameAddressCityStateZipHome PhoneCell PhoneSocial SecurityDate of Birth MM slash DD slash YYYY AgeGenderMaleFemaleMarital StatusSingleMarriedDivorcedWidowedTotal DependentsOccupationDepartmentDate of Hire MM slash DD slash YYYY Employee StatusPiece WorkerVolunteerSeasonalApprentice - IApprentice - IFull-TimePart-TimeNot EmployedRetiredOn-StrikeDisabledOtherDays Worked Per WeekTime Shift Begins (Indicate AM/PM)Time Shift Ends (Indicate AM/PM)WagesDate Injury Reported to Employer MM slash DD slash YYYY Has it been more 14 days since the accident occured? Yes NoList reason for delayHas Employee Returned to Work? Yes NoDate and Time of Return to WorkPaid for the day of injury? Yes NoPaid While Injured? Yes NoAccident InformationAccident Date MM slash DD slash YYYY Accident TimeAccident Location (address/department)Accident DescriptionWork Process Employee Engaged In at Time of AccidentWere Safeguards Provided? Yes NoWere Safeguards Used? Yes NoWas Accident on Premises? Yes NoDate Last Worked MM slash DD slash YYYY Was the accident fatal? Yes NoDate of fatality MM slash DD slash YYYY Nature of Injury/Body PartObject/Substance InvolvedName of WitnessesMedical Provider InformationProvider NameAddressCityStateZipPhoneComments
