Form 801 - Worker'S And Employer'S Report Of Occupational Injury Or Disease Page 2

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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:
6.
Male
Female
7. Education — grade
8. Hospitalized overnight as inpatient?
completed: (0 – 20)
Yes
No
(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
No
(
)
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
X
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
No
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
No
Unknown
38. Did injury occur during course of job?
Yes
No
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
No
:
to
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
S M
T
W
T
F
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
No
Yes
No
Yes
No
(If “Yes,” attach copy of eligibility card.)
57. Signature of employer representative:
58. Print name, title and phone:
59. Date:
X
Attention: Fatalities must be reported to DCBS/OR-OSHA
within eight hours of occurrence. Accidents
Department’s
D
D
DEPARTMENT OF
resulting in overnight hospitalization with medical treatment must be reported within 24 hours of employer notifica-
C
Copy
CONSUMER
B
tion to the DCBS/OR-OSHA local field office. Report fatalities or accidents by calling (503) 378-3272. After
BUSINESS
S
801
SERVICES
5 p.m., before 8 a.m., and on holidays and weekends, report by calling Oregon Emergency Response, (800) 452-0311.
440-801 (1/00/COM)
Original and copy to insurer within 5 days of notice of claim; copy to worker immediately as receipt of claim; copy to employer’s file.

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