Idaho > Workers Compensation > Claim
First Report Of Injury Or Illness IA-1 - Idaho
| First Report Of Injury Or Illness Form. This is a Idaho form and can be used in Claim Workers Compensation . |
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WORKERS COMPENSATION FIRST R EPORT OF INJURY OR ILLNESS Employer (Name & Address incl. zip) Carrier/Administrator Claim Number Report Purpose Code Jurisdiction Jurisdiction Claim No. Insured Report No. Employers Location Address (if different) Location No. l aGener Sic Code Employer FEIN Phone No. Carrier (Name, Address & Phone Number) Policy Period Claims Admin (Name, Address & Phone Number) To Check if self insured Carrier FEIN Policy Number or Self-Insured Number Administrator FEIN n s AdmiCarrier/ClaimAgent Name & Code Number Legal Name (Last, First, Middle) Birth Date Social Security Number Date Hired State of Hire Address (Incl. Zip) Sex Marital Status Occupation/Job Title Male Unmarried/ Single/Div. ee y Female Married Employment Status lo Unknown Separated p Phone No. of Dependents Unknown NCCI Class Code Em Wage Rate Day Month # Days Worked/WK Full Pay for Date of Injury? Yes No Week Other # Hrs Worked per Day Did Salary Continue? Yes No $ Time Employee AM Date of Injury Time AM Last Work Date Date Employer Notified Date Disability Began Work PM or Illness Occurred PM Began Employer Contact Name/Phone Number Type of Illness/Injury Part of Body Affected Did Injury/Illness Exposure Occur on Employers Yes Type of Illness/Injury Code Part of Body Affected Code Premises? No 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 nce Occurre How injury or illness/abnormal health condition occurred. Describe the sequence of events and include any objects or substances Cause of Injury that directly injured the employee or made the employee ill. Code Date Returned to Work If Fatal, Date of Death Were Safeguards or Safety Equipment Provided? Yes N o Were they used? Yes N o Physician/Health Care Provider (Name & Address) Hospital (Name & Address) Initial Treatment 0 No Medical Treatment 1 Minor: By Employer 2 Minor Clinic/Hosp 3 Emergency Care tmenTreat 4 Hospitalized 24 hr. Signature of Injured Employee, or Signature on File, Witness to Accident (Name & Phone Number) 5 Anticipated Major Med/Lost Date Time herOt Date Administrator Notified Date Prepared Preparers Name & Title Preparers Phone Number Filing this report is not an admission of liability. This repall ort shnot be evidence of any fact stated herein in any pinrog inceed 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)
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