Form Sfn 13660 - Employer'S Report Of Injury printable pdf download

EMPLOYER’S REPORT OF

500 EAST FRONT AVENUE

WCB Help

WCB HelpLine

Line

BISMARCK ND 58504-5685

1-800-777-5033

INJURY

TELEPHONE NUMBER (701) 328-3801

Questions? Call us. Report Injuries Immediately.

TOLL FREE FAX NUMBER 1-888-786-8695

WORKERS COMPENSATION BUREAU

TDD NUMBER (for the hearing impaired only)

ND Fraud and Safety Hotline

CLAIMS DIVISION

1-800-243-3331

(701) 328-3786

SFN 13660 (9/99)

Report Fraud and Unsafe Work Conditions.

PART 1

INJURED WORKER COMPLETE THIS PART OF FORM FOR ALL CLAIMS & SIGN THE FORM

Claim Number

Employer Acct. No.

Social Security No.

Injury Date

Birth Date

Sex

Marital Status

Single

Married

Area of Injury

Injured Worker’s Telephone No.

Employer’s Telephone No.

Time of Injury

a.m.

p.m.

Injured Worker’s Name and Address

Employer’s Name and Address

Exact address or location of injury - (city, county, state, and zip)

If injury occurred outside North Dakota when did you last work in

North Dakota?

What were you doing when injury occurred? How did it happen? Describe:

What were you hired to do? (job title or duties)

Date employer notified

Supervisor

Part of body injured (specify right or left, if applicable)

Have you had prior problems or injuries to

Yes

that part of the body? If yes, please complete the attached

C16 (Prior Injury Questionnaire)

Nature of injury (fracture, bruise, cut,

Date of first treatment

Years of education (circle one)

How long worked

Days

Weeks

etc.)

8 or less 9 10 11 12 13 14 15 16

for employer? __________

Months

Years

Treating doctor(s) name

Treating doctor(s) address

Hospital(s)

Hospital(s) address

Witness(es) to the injury

Witness(es) address

PART 2

PART 3

EMPLOYER COMPLETE THIS FORM ONLY IF WORKER WILL BE OFF THE JOB FOR FIVE OR MORE CONSECUTIVE DAYS

EMPLOYER COMPLETE THIS PART OF FORM FOR ALL CLAIMS

Days worked per week?

Working shift

Was worker

Yes

Was worker

IMPORTANT

paid for

in your employ

From ____________

date of injury?

when injured

Scheduled days off

How long has

Yes

Are you paying

____________

worker been

wages during

Varies

employed by you?

disability?

Wages not including

Hour

Week

Date left work

In which

Worker’s occupation

Time left work

state was

lodging and board

___________

Day

Month

worker hired?

If YES, monthly value

Does worker receive lodging?

Yes Board?

Yes

Is injured worker a

Lodging $__________ Board $________

Corp. Officer, Owner or Partner?

Does worker receive commissions?

How often is worker paid?

Yes

Will you have light

Did worker return to next

duty available?

Yes

Weekly

Biweekly

Monthly

Semimonthly

scheduled shift after injury?

Number of

Date of return to work

Estimated

Employment status

Season length

in months?

work days lost?

Actual

Full

time

Part

time

Seasonal

PART 4

EMPLOYER COMPLETE PART 4, THEN SIGN AND DATE FORM, AND SEND TO ND WORKERS COMPENSATION BUREAU

Employer’s name, address, city, state, and zip code

Worker’s Rate Class

Telephone No

Work Comp Acct

(

)

If injury site is non-North Dakota location,

last date work performed in North Dakota?

IMPORTANT

If you question this claim, state reason (continue on back)

FRAUD WARNING

By signing this form I acknowledge that I have read the Fraud Warning on the

reverse side of this form and understand that falsifying this claim or making a

I have the authority to execute this report.

false statement regarding this claim may be a FELONY, punishable by substantial

fines and imprisonment. By my signature below, I declare that the statements on

this form are true and accurate.

______________________

________________

______________

Employer’s Signature

Title

Date Signed

Date call received

Bureau Representative

Person Initiating Call

Form Sfn 13660 - Employer'S Report Of Injury

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