Form Pecd 1 - Employee'S Report Of Accident

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v. 10/10/2011
FORM PECD 1
EMPLOYEE’S REPORT OF ACCIDENT
PUBLIC EMPLOYEE CLAIMS DIVISION
Arkansas Insurance Department
1200 West Third, Little Rock, Arkansas 72201-1904
Telephone 501-371-2700 Facsimile 501-371-2733
TO BE COMPLETED BY EMPLOYEE:
Name: _______________________________________________ Tel #__________________________
Address: ____________________________________________________________________________
Birth Date: _______________ Marital Status: __________ Spouse’s Name: _______________________
Dependents Names and Ages: ___________________________________________________________
Education (Circle highest level completed) 1 2 3 4 5 6 7 8 9 10 11 12 GED College 1 2 3 4 5+
Present Employer: ____________________________________________________________________
Job Title: _____________________________________ Length of Employment: ___________________
If less than 5 years, list employers of last 5 years: ____________________________________________
____________________________________________________________________________________
Date of Accident: _________________ Time: ________ Place: _________________________________
Describe activity of employment engaged in at time of injury: ___________________________________
____________________________________________________________________________________
Describe how injury occurred: ___________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
To whom did you report the injury: ________________________________________________________
When: _____________________ Supervisor’s Name: ________________________________________
Nature and location of injury (describe part of body): _________________________________________
Doctor’s Name: _________________________ Family Doctor’s Name: __________________________
Who Selected Doctor? ____________________ Are you still under doctor’s treatment?______________
Date of First Visit? ________________ First Day Unable To Work? ______________________________
Have you ever collected compensation for a prior injury? ______________________________________
If yes, give details: ____________________________________________________________________
____________________________________________________________________________________
Have you ever received medical or chiropractic treatment to this part of the body before (either as a
workers’ compensation or a non-workers’ compensation injury)? ____ Yes ____ No. If yes, give details
including date: ________________________________________________________________________
Do you have child support obligations?___ Yes ____ No (
Child support obligation questions are required by Ark. Law)
If yes, are the obligations current or past due? _____ Current or ______ Past Due
To whom are the child support obligations payable? __________________________________________
Are you enrolled in the Medicare Program? ____ Yes ____ No (
Medicare question is required by federal law.)
Have you applied for Social Security Disability? __ Yes __ No
Date Applied for Social Security ____________
If you applied for social security disability, was your claim approved or denied? ___ Approved ___ Denied
Signed: _______________________________________ Date: _________________________________

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