First Report Of Injury Form - Minnesota Wcd
Download a blank fillable First Report Of Injury Form - Minnesota Wcd in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete First Report Of Injury Form - Minnesota Wcd with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Reset
First Report of Injury
Minnesota Department of Labor and Industry
Workers’ Compensation Division
PO Box 64221
See Instructions on Reverse Side
St. Paul, MN 55164-0221
PRINT IN INK or TYPE
F R 0 1
(651) 284-5030
Enter dates in MM/DD/YYYY format.
DO NOT USE THIS SPACE
1. EMPLOYEE SOCIAL SECURITY #
2. OSHA Case #
3. DATE OF CLAIMED INJURY 4. Time of
5. Time employee
am
am
injury
began work on date
pm
pm
of injury
6. EMPLOYEE Name (last, first, middle)
7. Gender
8. Marital
Married
M
F
Status
Unmarried
9. Home Address
10. Home phone #
11. Date of birth
City
State
Zip
Code
12. Occupation
13. Regular department
14. Date hired
15. Average weekly wage
16. Rate per hour
17. Hours per day
18. Days per week
19. Employment
Full time
Part time
Status
Seasonal
Volunteer
nd
20. Weekly value of:
Meals
Lodging
2
Income
21. Apprentice
Yes
No
22. Tell us how the injury occurred and what the employee was doing before the incident (give details). Examples: “Worker was driving lift truck with a pallet of boxes when
the truck tipped, pinning worker’s left leg under drive shaft.” “Worker developed soreness in left wrist over time from daily computer key entry.”
23. What was the injury or illness (include the part(s) of body)? Examples: chemical
24. What tools, equipment, machines, objects, or substances were involved?
burn left hand, broken left leg, carpal tunnel syndrome in left wrist.
Examples: chlorine, hand sprayer, pallet lift truck, computer keyboard.
25. Did injury occur on employer’s premises?
26. Date of first day of any lost time
27. Employer paid for lost time on day of injury (DOI)
Yes
No
Yes
No
No lost time on DOI
If no, indicate name and address of place of occurrence
28. Date employer notified of injury
29. Date employer notified of lost time
30. Return to work date
31. Date of death
32. TREATING PHYSICIAN (name, address, and phone)
33. HOSPITAL/CLINIC (name and address) (if any)
34. Emergency Room Visit
Yes
No
35. Overnight in-patient
Yes
No
36. EMPLOYER Legal name
37. EMPLOYER DBA name (if different)
38. Mailing address
39. Employer FEIN
40. Unemployment ID#
City
State
Zip
Code
41. Employer’s contact name and phone #
42. Physical address (if different)
43. Witness (name and phone)
City
State
Zip
Code
44. NAICS code
45. Date form completed
46. INSURER name
51. CLAIMS ADMIN COMPANY (CA) name (check one)
Insurer
SFM MUTUAL INSURANCE COMPANY
TPA
SFM MUTUAL INSURANCE COMPANY
47. Insured legal name
52. CA address
CLAIMS SERVICES, PO BOX 9416
48. Policy # or self-insured certificate #
City
State
Zip
Code
MN
MINNEAPOLIS
55440-9416
49. Insurer FEIN
50. Date insurer received notice
53. CA FEIN
54. Claim #
41-1459789
41-1459789
MN FR01 (5/08)
Copies to: Insurer, Employer, Employee, and Workers’ Compensation Division (if no insurer)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business