First Report Of Injury
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1
2FIRST REPORT OF INJURY
To report a claim:
Call 303.361.4000 or 800.873.7242
Or Fax to 303.361.5000 or 888.329.2251
Or, go to
PLEASE PRINT CLEARLY
Early reporting can save you money. Report all injuries immediately!
The information below allows Pinnacol Assurance’s customer service representatives to quickly and accurately process your claim. Use the completed form as a guide when
reporting by phone or online to save you time. Don’t wait to report if you don’t have all the answers.
POLICY INFORMATION
Policy Number: _______________________________ Company Name: ______________________________________________________
Address or Location (if different than mailing address): _______________________________________________________________
Prepared by: __________________________________________________ Title: __________________________________________
Please Print
E-mail: ______________________________________________ Fax: (______) _______-__________
Phone: (______) _______-__________
Date Completed: ________ /________ /________
INJURED WORKER INFORMATION
Injured Worker’s Social Security Number: _________-__________-______________ Date of Injury: ________ /________ /________
First Name: ____________________________ M.I. ____ Last Name: _______________________________________
Home/Mailing Address: _____________________________________________________________ Phone: (______) _______-__________
City
State
Zip Code
Date of Birth: ________ /________ /________
Male
Female
Martial Status: ___________________________
Language:
English
Spanish
Other: ____________________ E-mail: ______________________________________________
Occupation: _____________________________________________ Date Hired: ________ /________ /________
Employee Status:
Full-time
Part-time
Seasonal
Volunteer
Independent Contractor
Days Worked per Week: ____________ Hours Worked per Day: ____________
Pay Rate: _________________
Hourly
Weekly
Monthly
Annually
Other: __________________
ACCIDENT / INJURY INFORMATION
Fatal Injury:
Yes
No
If Fatal Injury: Date of Death ________ /________ /________
Time of Injury: ____________
am
pm Time Work Began: ____________ Last Day Worked: ________ /________ /________
Full Pay on Date of Injury:
Yes
No
Accident Occurred on Employers Premises:
Yes
No
If Applicable: Location Code: ____________ Dept Code: ____________
Accident Location: _____________________________________________________________________________________
City
State
Zip Code
Name of Employer Representative Notified: _______________________________________ Date Notified: ________ /________ /________
Witnesses: __________________________________________________________________________________________________________
Name(s) and Phone Number(s)
How Did the Injury Occur: _____________________________________________________________________________________________
Attach Additional Information if Necessary
Specific Activity the Employee Was Engaged In: _____________________________ What Equipment Was Being Used: ________________
Body Part(s) Injured: _____________________________________________
Right
Left
Not Applicable
Type of Injury Sustained: __________________________________________
Safety Equipment Provided
Safety Equipment Used
Possible Drug/Alcohol Involved
Employer Questioning Liability
RETURN TO WORK INFORMATION
Has the Injured Worker Returned to Work?
Yes
No
Date Returned to Work: ________ /________ /________
Estimated Return to Work Date: ________ /________ /________
Is this a lost time Claim?
Yes
No (Claim is lost time if there is a loss of more than three scheduled work days due to the injury).
MEDICAL PROVIDER INFORMATION: Where Was Your Employee Treated?
No Medical Treatment
Treated by Employer
911 Called
Walk-In Clinic
Emergency Room
Hospitalized > 24 hrs/Overnight
Possible Surgery
___________________________________________________________________________________________________________________
Medical Provider Name
Street Address
City
State
Zip Code
Phone
Updated 03/15
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