Form Twcc 1 - Employer'S First Report Of Injury Or Illness - 1997

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Send the specified copies to your
Workers' Compensation Insurance Carrier
and the injured employee.
TWCC CLAIM #
*Employers - Do not send this form to the
Texas Workers' Compensation Commission,
unless the Commission specifically requests a direct
filing.
CARRIER'S CLAIM #
EMPLOYER'S FIRST REPORT OF INJURY OR ILLNESS
1. Name (Last, First, M.I.)
2. Sex
15. Date of Injury (m-d-y)
16. Time of Injury
17. Date Lost Time Began
F
M
(m-d-y)
-
-
:
am
pm
-
-
3. Social Security Number
4. Home Phone
5. Date of Birth (m-d-y)
18. Nature of Injury*
19. Part of Body Injured or Exposed*
-
-
(
)
-
-
6. Does the Employee Speak English?
If No, Specify Language
20. How and Why Injury/Illness Occurred*
YES
NO
7. Race
8. Ethnicity
21. Was employee
22. Worksite Location of Injury (stairs, dock, etc.)*
Hispanic
White
doing his
YES
regular job?
NO
Native American
Black
Asian
Other
9. Mailing Address
Street or P.O. Box
23. Address Where Injury or Exposure Occurred Name of business if incident
occurred on a business site
City
State
Zip Code
County
Street or P.O. Box
County
10. Marital Status
City
State
Zip Code
Married
Widowed
Separated
Single
Divorced
11. Number of Dependent Children
12. Spouse's Name
24. Cause of Injury(fall, tool, machine, etc.)*
13. Doctor's Name
25. List Witnesses
14. Doctor's Mailing Address (Street or P.O.Box)
26. Return to work
27. Did employee
28. Supervisor's
29. Date Reported
(m-d-y)
date/or expected
die?
Name
(m-d-y)
City
State
Zip Code
YES
NO
-
-
-
-
30. Date of Hire (m-d-y)
31. Was employee hired or recruited in Texas?
32. Length of Service in Current Position
33. Length of Service in Occupation
-
-
YES
NO
Months
Years ______
Months
Years ______
34. Employee Payroll Classification Code
35. Occupation of Injured Worker
36. Rate of Pay at this Job
37. Full Work Week is:
38. Last Paycheck was:
39. Is employee an Owner, Partner,
or Corporate Officer?
Hours
Days
$
Hourly
$
Weekly
$
for
Hours or
Days
YES
NO
40. Name and Title of Person Completing Form
41. Name of Business
42. Business Mailing Address and Telephone Number
43. Business Location (If different from mailing address)
Street or P.O. Box
Telephone
Number and Street
(
)
City
State
Zip Code
City
State
Zip Code
44. Federal Tax Identification Number
45. Primary Standard Industrial Classification (SIC) Code*
46. Specific SIC Code*
47. Texas Comptroller Taxpayer No.
(4 digit)
(4 digit)
48. Workers' Compensation Insurance Company
49. Policy Number
50. Did you request accident prevention services in past 12 months?
YES
NO
If yes, did you receive them?
YES
NO
51. Signature and Title (READ INSTRUCTIONS ON INSTRUCTION SHEET BEFORE SIGNING)
X
Date ________________________________________
TWCC 1 (Rev. 6/97)
Rule 120.2

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