Form 801 - Worker'S And Employer'S Report Of Occupational Injury Or Disease printable pdf download

FEIN of claim administrator:

State of Oregon

Worker’s and Employer’s

Report of Occupational

Insurer claim number:

Injury or Disease

Complete all items — Failure to do so may delay benefits

1. Worker’s legal name (first, m.i., last):

2. Home phone:

3. Date of birth:

4. Social Security number (see back of form):

(

)

5. Worker’s street, mailing, and e-mail address:

Male

Female

7. Education — grade

8. Hospitalized overnight as inpatient?

completed: (0 – 20)

Yes

(If emergency room-only, mark “No”)

○

9. Nature of injury/disease

10. Name and city of hospital:

(strain, cut, bruise, etc.):

○

City

State

ZIP

11. Body part(s) affected:

12. Name and address of health insurance provider:

Left

Right

13. Date of injury/disease:

14. Time of injury:

15. Has body part been injured before?

16. Full name, address, and phone no. of attending physician:

(If yes, explain)

a.m

p.m.

Yes

(

)

17. Describe accident fully (please print)

Witness(es):

18. By my signature I am giving NOTICE OF CLAIM and authorizing medical providers and other custodians of claim records to release relevant medical records. I

certify that the above information is true to the best of my knowledge and belief (see paragraphs 3 and 4 on the back). By my signature, I also authorize the use of my

SSN as described in paragraph 2 on the back. (If you do not authorize the use of your SSN as described in paragraph 2 on back, check here

Worker: Sign and give form to your employer for completion

19. Employer’s legal business name:

20. Employer BIN:

Worker signature

Date

Dept. use

Employer: Complete items 24-27 only if worker is a leased employee.

21. Employer’s street and email address:

22. Employer FEIN:

24. Client’s legal business name:

25. Client BIN:

Emp no

○

City

State

ZIP

23. Insurer policy #:

26. Client’s street and email address:

27. Client FEIN:

Ins no

○

28. Nature of business:

29. Worker class code:

City

State

ZIP

Occ

30. Worker’s occupation (do not abbreviate):

31. Is worker an owner or

32. Address of injury site if different from 21 or 26:

Nature

corp. officer?

Yes

○

33. Date employer first knew of claim:

34. If fatal, date of death:

City

State

ZIP

Part

35. Date of hire:

36. State of hire:

37. Injured on employer’s or client’s premises?

Event

Yes

Unknown

38. Did injury occur during course of job?

Yes

Unknown

39. Date left work:

40. Time left work:

41. Date returned to regular work:

Source

○

42. Date returned to work with restrictions/light duty:

a.m

p.m.

○

Assoc

43. Working

44. No. of hours worked per shift:

45. If returned to work with restrictions,

from

a.m

p.m.

object

shift:

were full wages paid?

Yes

a.m

p.m.

46.Wage and wage period:

47. If wage varies or includes other earnings

(tips, room and board, commission, etc.)

Insurer use

Hr.

Day

per

give total weekly wage and explain:

(Attach payroll records for last 52 weeks prior to date of injury)

Wk.

Mo.

Yr.

48. Scheduled days off:

49. Number of days

worked per week:

S M

50. Department and location where event occurred:

51. All equip., materials, or chemicals employee was using when event occurred:

52. Specific activity the employee was engaged in when event occurred. (Indicate if activity was part of normal job duties):

53. How injury or illness occurred; describe the sequence of events and include any objects or substances that directly injured the employee or made the employee ill:

54. Was accident caused by person

55. Were other workers injured

56. Is worker “premium exempt”

(

)

(a Preferred Worker)?

other than injured worker

or by failure of machinery or product?

in the accident?

Yes

(If “Yes,” attach copy of eligibility card.)

57. Signature of employer representative: