Iowa > Workers Compensation
Employers First Report Of Injury Or Illness 14-0001 - Iowa
| Employers First Report Of Injury Or Illness Form. This is a Iowa form and can be used in Workers Compensation . |
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Iowa Workers' Compensation FIRST REPORT OF INJURY OR ILLNESS Claim Administrator Name: CLAIM ADMIN Mailing Address, City, State, & Postal Code: Jurisdiction Code______________ Claim Representative Business Phone Number: Claim Administrator Claim Number: Claim Administrator FEIN: Jurisdiction Claim Number_______________ Insurer Name (if different than claim administrator): Insurer FEIN: Claim Type Code: Insured Report Number: Employer Type Code: __ Employer (E) __ Lessor (L) Employer UI Number: Employer Name: Employer FEIN: EMPLOYER Physical Address, City, State, & Postal Code: Mailing Address, City, State, & Postal Code: Industry Code: Insured Location Number: Nature of Business: Insured Name (parent company if different than employer): POLICY Insured FEIN: Insured Postal Code: Employer Contact Name and Business Phone Number: Policy/Contract Number: Coverage Effective Date: Coverage Expiration Date: Self Insurance License/ Certificate Number: Employee Name (First, Middle, Last, & Suffix): Date of Birth: Gender: __ Male (M) __ Female (F) Tax Filing Status (check one): ____ Single (A) ____ Single/Head of Household (B) ____ Married/Filing Joint (C) ____ Married/Filing Separate(D) Marital Status: (check one) ___ Unmarried (U) ___ Married (M) ___ Separated (S) Employee's Authorization to Release the Following: Medical Records Social Security Number __ yes __ yes __ no __ no Mailing Address, City, State, & Postal Code: Date of Hire: Educational Level (grade completed): _______ [GED = 12] Employment Status (check one): EMPLOYEE Phone Number (include area code): Occupation Description: ____ Piece Worker ____ Volunteer ____ Seasonal ____ Apprenticeship/Full-Time Manual Classification Code: Department Where Regularly Worked: ____ Apprenticeship/Part-Time ____ Regular Employee/Full-Time ____ Part-Time ____ Other Employee ID Number (check one): ID # ______________________ ____ Social Security Number ____ Employment VISA Number ____ Passport Number ____ Green Card ____ Employee ID Assigned by Jurisdiction ___ yes ___ yes ___ no ___ no Average Wage $ ___________ (check one): WAGE ___ hourly ___ bi-weekly ___ daily ___ annual ___ semi-monthly ___ weekly ___ monthly Salary Continued In Lieu of Compensation: Full Wages Paid for Date of Injury: Employee Number of Dependents: __________ Employee Number of Exemptions: ___________ (check one) Number of Days Regularly Worked Per Week: _______ _____________________ Date of Injury _____________________ Date Employer Had Knowledge of the Injury _____________________ Date Claim Administrator Had Knowledge of the Injury _____________________ Initial Date Last Day Worked _____________________ Initial Return to Work Date (if applicable) _____________________ Employee Date of Death (if applicable) _____________________ Time of Injury _____________________ Time Employee Began Work Pre-Existing Disability Code: ACCIDENT/INJURY ___ Yes ___ No ___ Unknown Accident Premises Code: ___ Employer (E) ___ Lessee (L) ___ Other (X) Accident Site Organization Name: Discontinued Fringe Benefits: $_____________ Describe the nature of the injury. (ex. amputation, burn, cut, fracture): ___ Entitled ___ Withholding Part(s) of body directly affected by the injury or illness. (ex. hand, arm, circulatory system): Describe the events that caused the injury. (ex. fell, operating machinery, chemical exposure): Name the object or substance that directly injured the employee. (ex. knife, floor, acid, oil): Accident Site Street, City, State, & Postal Code: Specify activity the employee was engaged in when the event occurred. (ex. cutting metal plate for flooring) Indicate if activity was part of normal duties: Accident Location Narrative (if no street address): Accident Site County/Parish: Initial Treatment Code (check one): ___ no medical treatment (0) ___ minor/on-site treatment (1) ___ clinic/hospital visit (2) ___ emergency care (3) ___ hospitalization > 24 hours (4) ___ future medical treatment/lost time anticipated (5) Preparer's Name & Title: Witness Name & Business Phone Number: Initial Medical Provider Name: Managed Care Organization Name or ID Number: MEDICAL Initial Medical Provider Physical Address, City, State, & Postal Code: ICD Primary Diagnostic Code (if known): Preparer's Company Name: Phone Number: Date: © IAIABC FORM 1.2 (12/98) American LegalNet, Inc. www.FormsWorkflow.com This section is to provide information valuable in handling this claim. The Iowa Occupational Safety and Health Act The following is a summary of the recordkeeping, reporting and posting responsibilities of employers under Iowa's Occupational Safety and Health Act. RECORDKEEPING REQUIREMENTS Regulations issued under the Iowa Occupational Safety and Health Act of 1972 require establishments subject to the Act to maintain records of recordable occupational injuries and illness. Such records must consist of: (a) a log and summary of occupational injuries and illnesses and (b) a supplementary record of each occupational injury and illness. LOG AND SUMMARY OF OCCUPATIONAL INJURIES AND ILLNESSES. Each recordable occupational injury and occupational illness must be entered on a log and summary of cases (0SHA Form No. 200) as early as practicable but no later than six working days after receiving information that a recordable case has occurred. A multi-unit employer may maintain the log and summary of occupational injuries and illnesses at a place other than the establishment if there is a copy of the log and summary available in the establishment complete and current to a date within 45 calendar days. If an equivalent of OSHA Form No 200 is used, such as a printout from data-processing equipment, the information shall be as readable and comprehensible to a person not familiar with the dataprocessing equipment as the OSHA Form No. 200 itself. Logs must be kept current and retained for 5 years following the end of the calendar year to which they relate. SUPPLEMENTARY RECORD OF OCCUPATIONAL INJURIES AND ILLNESSES. To supplement the Log and Summary of Occupational Injuries and Illnesses, each employer must have available a record for each occupational injury or illness at each establishment within six working days after receiving information that a recordable case has occurred, OSHA Form No. 101 may be used for this purpose. State of Iowa Form No. 140001 [(IAIABC Form 1.2 (12/98)], workers' compensation or other reports are acceptable as records if they contain the information required on OSHA Form No 1
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