First Report of Injury Or Illness {14-001} | Pdf Fpdf Doc Docx | Iowa

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First Report of Injury Or Illness {14-001} | Pdf Fpdf Doc Docx | Iowa

First Report of Injury Or Illness {14-001}

This is a Iowa form that can be used for Workers Compensation.

Alternate TextLast updated: 7/21/2016

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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. !!!!!!!!!!!!!! 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