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Employers First Report Of Occupational Injury Or Disease 8 WC - New Hampshire

Employers First Report Of Occupational Injury Or Disease Form. This is a New Hampshire form and can be used in General Workers Comp .
 Fillable pdf Last Modified 8/13/2015
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LAB 500 New Hampshire Employee Name (First & Last) ID Type - Employee ID Employee Address Employer's First Report of Injury Submission Date: EMPLOYEE INFORMATION Gender Date of Birth Telephone Age Hired Date Occupation when Injured Hrs per Day Days per Week WEB-8WC ­ NHDOL# Hired in NH Wages per Hour Average Weekly Earnings INJURY INFORMATION Injury Date / Time Disability Began Date Claim Type Accident Description Full Wages Paid on Injury Date Date Employer Notified of Injury Location/Jobsite & Business Name where accident occurred Body part Injured Cause of Injury Nature of Injury Witness Name Witness Phone Returned to work? Initial Treatment If so, what date? If so, at what occupation? If so, at what duty status? Initial Treatment Date Name of Treating Physician Name of Treating Hospital Has injured died? If so, what date EMPLOYER INFORMATION Employer Name Employer FEIN Industry Code Employer Contact Name Managed Care Organization Leased Employee? Client Company Contact Phone Number Employer Business Address OCIP/Wrap-Up Policy? Name of policy holder INSURER INFORMATION Insurance Carrier Insurer Type Policy Number Telephone Number SUBMITTER INFORMATION Submitter Name Title of Submitter Represents Telephone Number 8WC (12/2014) To file this report, email to WorkersComp@dol.nh.gov, Fax Number: (603)271-6149 or Mail to: NH Department of Labor Workers' Compensation Division 95 Pleasant St. Concord NH 03301 American LegalNet, Inc. www.FormsWorkFlow.com
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