First Report Of Injury
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1
2NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION
EMPLOYERS' FIRST REPORT OF INJURY OR ILLNESS
2410 CENTRE AVE. SE PO BOX 27198
ALBUQUERQUE, NM 87125-7198
OFFICIAL USE ONLY
PLEASE PRINT IN BLACK INK OR TYPE.
EMPLOYER ( NAME & ADDRESS INCL ZIP )
CARRIER / ADMINISTRATOR CLAIM #
REPORT PURPOSE CODE
OSHA LOG NUMBER
G
JURISDICTION
JURISDICTION CLAIM NUMBER
E
N
INSURED REPORT NUMBER
E
R
LOCATION #
EMPLOYER'S LOCATION ADDRESS ( IF DIFFERENT )
A
PHONE NUMBER
EMPLOYER FEIN
INDUSTRY CODE
L
C
CARRIER ( NAME, ADDRESS & PHONE NO )
POLICY PERIOD
CLAIMS ADMINISTRATOR ( NAME, ADDRESS & PHONE NO )
TO
A
C
L
R
A
I
M
CHECK IF APPROPRIATE
R
S
SELF INSURANCE
I
A
D
CARRIER FEIN
POLICY / SELF-INSURED NUMBER
ADMINISTRATOR FEIN
M
E
I
N
AGENT NAME & CODE NUMBER
R
NAME ( LAST, FIRST, MIDDLE )
DATE OF BIRTH SOCIAL SECURITY NUMBER
DATE HIRED
STATE OF HIRE
E
M
ADDRESS ( INCL ZIP )
GENDER
MARITAL STATUS
OCCUPATION/JOB TITLE OR (SOC)
CODE
MALE
UNMARRIED
P
SINGLE/DIVORCED
L
FEMALE
MARRIED
EMPLOYMENT STATUS
O
Y
UNKNOWN
SEPARATED
E
PHONE NUMBER
# OF DEPENDENTS
NCCI CLASS CODE
UNKNOWN
E
RATE
PER:
MONTH
# DAYS WORKED/WEEK
FULL PAY FOR DAY OF INJURY?
YES
NO
W
DAY
A
G
OTHER:
DID SALARY CONTINUE?
YES
NO
WEEK
E
TIME EMPLOYEE
DATE OF INJURY/ILLNESS
TIME OF
LAST WORK
DATE EMPLOYER
DATE DISABILITY BEGAN
AM
AM
OCCURRENC
DATE
NOTIFIED
BEGAN WORK
E
PM
PM
O
CONTACT NAME / PHONE NUMBER
TYPE OF INJURY/ILLNESS
PART OF BODY AFFECTED
C
DID INJURY/ILLNESS EXPOSURE OCCUR ON EMPLOYER'S PREMISES?
TYPE OF INJURY / ILLNESS CODE
PART OF BODY AFFECTED CODE
C
YES
NO
DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE
ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN
U
OCCURRED
ACCIDENT OR ILLNESS EXPOSURE OCCURRED
R
SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR
WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS
ILLNESS EXPOSURE OCCURRED
EXPOSURE OCCURRED
R
E
HOW INJURY OR ILLNESS / ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT
DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL.
N
CAUSE OF INJURY CODE
C
DATE RETURNED TO WORK
IF FATAL, GIVE DATE OF DEATH
WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED?
NO
YES
E
WERE THEY USED?
YES
NO
PHYSICIAN / HEALTH CARE PROVIDER ( NAME & ADDRESS )
HOSPITAL ( NAME & ADDRESS )
INITIAL TREATMENT
T
R
NO MEDICAL TREATMENT
E
A
MINOR: BY EMPLOYER
T
M
MINOR CLINIC/HOSPITAL
E
N
EMERGENCY CARE
T
WITNESSES ( NAME & PHONE # )
HOSPITALIZED > 24 HRS
O
FUTURE MAJOR MEDICAL/
T
LOST TIME ANTICIPATED
H
DATE ADMINISTRATOR NOTIFIED
DATE PREPARED
PREPARER'S NAME & TITLE
E
R
FORM IA-1 (7/02) IAIABC 2002
NM WCA FORM E1.2
EQUIVALENT TO OSHA'S FORM 301
Completion of this form is not an admission that the claim is compensable under the Workers’ Compensation Act.
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