Employers Report Of Injury Or Disease Page 2
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TYPE OF INJURY CODE
PART OF BODY AFFECTED CODE
CAUSE OF INJURY CODE (ENTER CODES, IF KNOWN)
TYPE OF INJURY OR ILLNESS
PARTS OF BODY AFFECTED
CAUSE OF INJURY
DID INJURY OR ILLNESS OCCUR
IF OUT OF STATE, SPECIFY
WERE SAFEGUARDS OR SAFETY
WERE SAFEGUARDS OR SAFETY
ON EMPLOYER’S PREMISES?
STATE OF INJURY
EQUIPMENT PROVIDED?
EQUIPMENT USED?
YES
YES
YES
NO
NO
NO
ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED
HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES DIRECTLY RESPONSIBLE.
INITIAL TREATMENT:
IF FATAL, GIVE DATE OF DEATH
NO MEDICAL TREATMENT
-
-
MINOR BY EMPLOYEE
MONTH
DAY
YEAR
CLINIC / HOSPITAL
PHYSICIAN/HEALTH CARE PROVIDER
PANEL PHYSICIAN
FIRST NAME:
LAST NAME:
EMPLOYEE PHYSICIAN
STREET
EMERGENCY CARE
HOSPITALIZED MORE THAN 24 HOURS
CITY
STATE
ZIP
POLICY PERIOD FROM:
-
-
HOSPITAL NAME:
MONTH
DAY
YEAR
STREET
POLICY PERIOD TO:
CITY
STATE
ZIP
-
-
POLICY/SELF INSURED NUMBER:
MONTH
DAY
YEAR
WITNESS FIRST NAME
WITNESS PHONE NUMBER
-
-
WITNESS LAST NAME
PERSON COMPLETING THIS FORM:
INSURANCE CARRIER OR THIRD PARTY ADMINISTRATOR (IF SELF-INSURED)
NAME:
NAME:
TITLE:
STREET
PHONE:
ZIP
CITY
STATE
BUREAU CODE:
FEIN:
DATE PREPARED
-
-
MONTH
DAY
YEAR
Any individual filing misleading or incomplete information knowingly and with intent to
defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act
and may also be subject to criminal and civil penalties through Pennsylvania Act 165.
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