Form Erd - 991 - First Report Of Injury And Occupational Disease

First Report

Adjuster date Stamp

of Injury and Occupational Disease

Montana Department of Labor and Industry

P.O. Box 8011, Helena, MT 59604-8011

Worker

Last Name

First Name

M.I.

Date of Birth

Social Security Number

Home address

City

State

Postal Code

Phone Number

Education

Less Than High School

Gender

Marital Status

Married

Number of

GED or High School Diploma

Male

Unknown

Separated

Dependants

Beyond High School

Female

Not Married

Unknown

Wages

Date Hired

Gross earnings for

Date/Amount

Date/Amount

Date/Amount

Date/Amount

four pay periods preceding the injury

/

/

/

/

Employment Status

Wage:

Hour

Week

Month

Other:

Number of days

worked per week

Full Time

Part Time

Seasonal

Volunteer

:

Day

BI-weekly

Year

In addition to gross earnings cited above worker received:

Estimated value if any:

Board & Room

Overtime

Bonus

Commissions

Other:

Worked next scheduled shift

Off work more than 6 work days

Date Last Worked

Date of Return to work

Full wages paid for date of

Salary continued?

Yes

No

Yes

No

Not Sure

Injury?

yes

No

Yes

No

Accident Description

Description of Accident::

Cause of Injury

Cause

Part of Body

Part Code

Nature of Injury

Nature

Date and Time of Injury

/

Code

Code

Date disability began:

Date of Death:

Names of witnesses:

1)

2)

3)

Accident on employer’s:

Accident address or location:

premises?

Yes

No

City:

State:

Postal code:

Date employer notified:

Accident reported to:

Safety equipment provided?

Safety equipment used?

Yes

No

Yes

No

Medical

Attending Physician’s name:

Address:

State:

Postal Code:

Phone number:

Hospital name:

Address:

State:

Postal Code:

Phone number:

Type of initial medical treatment received:

No treatment

Emergency room

Treatment on-site by employer or medical Staff

Clinic/Dr. Office

Hospital

Signature

This is my claim for workers’ compensation benefits due to the on-the-job injury, occupational disease or death of the above named worker. I understand that signing this

claim for compensation authorizes the release of rehabilitation records, Social Security records and health care information (medical records) relevant to this claim to the

workers’ compensation insurer and the insurer’s agents. I also understand that if I obtain or exert unauthorized control over workers’ compensation benefits, I may be fined

and/or imprisoned.

Signature of Injured Worker or Beneficiary:

Date:

Employer

Employer name:

Doing Business as:

Federal Employer Identification Number (tax I.D.)

Mailing Address:

City:

State:

Postal Code:

Phone Number:

Location of operation, if different from mailing address:

Nature of Business or SIC Code:

Self-Insured?

Yes

No

Employer is a

Sole Proprietorship

Partnership

Injured worker is a

Sole Proprietorship

Partnership

A member of the employer’s (sole proprietor or)

Corporation

Limited Liability Company

Corporation

Limited Liability Company

family living in the employer’s household.

Do you have any

If yes, please explain fully. Use separate sheet if you need additional space.

Was worker injured while in

reason to question

Yes

No

your employ?

yes

no

this accident?

Prepared by:

Official title:

Date:

Payroll Classification Code

Under which you report

Employee’s wages:

Authorized Employer’s Signature:____________________________________ Date:__________________________

Insurer Only

Claim Administrator’s Claim Number:

Date reported to

The above information is correct with the following exceptions:

Claim Administrator:

(Attach extra sheets if box at right is checked)

Third Party Administrator’s Name:

Claim Administrator’s Address:

Insurer FEIN:

Insurer’s Name:

Third Party Administrator’s FEIN:

Policy Number:

Policy Effective Date:

Policy Expiration Date:

ERD – 991 (Rev. 4/2000 LW)