Iaiabc Form 1.2 - First Report Of Injury Or Illness

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Iowa Workers’ Compensation – FIRST REPORT OF INJURY OR ILLNESS
Jurisdiction Code______________
Jurisdiction Claim Number_______________
Claim Administrator Name:
Claim Representative Business
Insurer Name
(if different than claim administrator):
Phone Number:
Mailing Address, City, State, & Postal Code:
Claim Administrator Claim Number:
Insurer FEIN:
Claim Administrator FEIN:
Claim Type Code:
Employer Name:
Employer FEIN:
Insured Report Number:
Employer Type Code:
__ Employer (E)
__ Lessor (L)
Physical Address, City, State, & Postal Code:
Mailing Address, City, State, & Postal Code:
Industry Code:
Insured Location Number:
Employer UI Number:
Nature of Business:
Employer Contact Name and Business Phone Number:
Insured Name
Insured FEIN:
Insured Postal Code:
Policy/Contract Number:
Coverage Effective Date:
Self Insurance License/
(parent company if different than employer):
Certificate Number:
Coverage Expiration Date:
Employee Name
Date of Birth:
Tax Filing Status
(First, Middle, Last, & Suffix):
(check one):
__ Male (M)
____ Single (A)
____ Married/Filing Joint (C)
Mailing Address, City, State, & Postal Code:
Date of Hire:
__ Female (F)
____ Single/Head of Household (B)
____ Married/Filing Separate(D)
Educational Level
Marital Status:
(grade completed): _______ [GED = 12]
(check one)
Employment Status (
Employee ID Number
check one):
(check one):
___ Unmarried (U)
Phone Number
____ Piece Worker
ID # ______________________
(include area code):
___ Married (M)
____ Volunteer
Occupation Description:
____ Social Security Number
___ Separated (S)
____ Seasonal
____ Apprenticeship/Full-Time
____ Employment VISA Number
Employee’s Authorization to
____ Apprenticeship/Part-Time
Release the Following:
Manual Classification Code:
____ Passport Number
____ Regular Employee/Full-Time
Medical Records
__ yes
____ Part-Time
____ Green Card
Department Where Regularly Worked:
____ Other
____ Employee ID Assigned by Jurisdiction
Social Security Number
__ yes
Average Wage $ ___________
(check one):
Salary Continued In Lieu of Compensation:
___ yes
___ no
Employee Number of Dependents: __________
___ hourly
___ daily
___ semi-monthly
___ monthly
Employee Number of Exemptions: ___________
Full Wages Paid for Date of Injury:
___ yes
___ no
___ bi-weekly
___ annual
___ weekly
___ Entitled
Number of Days Regularly Worked Per Week: _______
Discontinued Fringe Benefits: $_____________
___ Withholding
Describe the nature of the injury. (ex. amputation, burn, cut, fracture):
_____________________ 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)
Part(s) of body directly affected by the injury or illness. (ex. hand, arm, circulatory system):
_____________________ Employee Date of Death (if applicable)
_____________________ Time of Injury
_____________________ Time Employee Began Work
Pre-Existing Disability Code:
Describe the events that caused the injury. (ex. fell, operating machinery, chemical exposure):
___ Yes
___ No
___ Unknown
Accident Premises Code:
___ Employer (E)
___ Lessee (L)
Name the object or substance that directly injured the employee. (ex. knife, floor, acid, oil):
___ Other (X)
Accident Site Organization Name:
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:
Witness Name & Business Phone Number:
Initial Treatment Code
Initial Medical Provider Name:
Managed Care Organization Name or ID Number:
(check one):
___ no medical treatment (0)
___ minor/on-site treatment (1)
___ clinic/hospital visit (2)
Initial Medical Provider Physical Address, City, State, & Postal Code:
___ emergency care (3)
ICD Primary Diagnostic Code
(if known):
___ hospitalization > 24 hours (4)
___ future medical treatment/lost time anticipated (5)
Preparer’s Name & Title:
Preparer's Company Name:
Phone Number:
IAIABC FORM 1.2 (12/98)


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