Form Mn Fr01 - First Report Of Injury

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MN Department of Labor and Industry
First Report of Injury
Workers’ Compensation Division
See Instructions on Reverse Side
PO Box 64221
Reset
St. Paul, MN 55164-0221
PRINT IN INK or TYPE
F R 01
(651) 284-5032 or 1-800-342-5354
ENTER DATES IN MM/DD/YYYY FORMAT
Fax: (651) 284-5731
DO NOT USE THIS SPACE
1. EMPLOYEE SOCIAL SECURITY # 2. OSHA case #
3. Time employee began
am
work on date of injury
pm
4. DATE OF CLAIMED INJURY 5. Time
6. Date of death
# of dependents (if death
am
of injury
is related to injury)
pm
7. EMPLOYEE Name (last, suffix, first, middle)
8. Gender
9. Marital
Married
status
M
F
Unmarried
10. Home address
11. Home phone #
12. Date of birth
13. Date hired
City
State
Zip Code
14. Occupation
15. Regular department
16. Apprentice
Yes
No
17. Average weekly wage 18. Rate per
19. Hours per
20. Days per
Normal work schedule Sun - Sat
21. Employment
Full time
Part time
hour
day
week
S
M
T
W
T
F
S
status (check all
Seasonal
Volunteer
that apply)
22. Tell us how the injury/illness occurred, what the employee was doing before the incident (give details), and what the injury/illness was. Examples: “Worker was driving
lift truck with a pallet of boxes when the truck tipped, pinning worker’s left leg under drive shaft.” “Worker developed soreness in left wrist over time from daily computer key entry.”
23. What was the injury or illness (include the part(s) of body)? Examples:
24. What tools, equipment, machines, objects, or substances were involved?
chemical burn left hand, broken left leg, carpal tunnel syndrome in left wrist.
Examples: chlorine, hand sprayer, pallet lift truck, computer keyboard.
25. Did injury occur on employer’s premises?
26. First date of any lost time
27. Employer paid for lost time on day of injury (DOI)
Yes
No
Yes
No
No lost time on DOI
Name and address of the place of the occurrence
28. Date employer notified of injury
29. Date employer notified of lost time
30. Return to work date
31. RTW same employer
32. RTW with restrictions
Yes
No
Yes
No
33. Treating physician (name)
34. Extent of medical treatment (check all that apply)
None
Minor on-site by employer’s medical staff
Minor clinic/hospital
35. Certified Managed Care Organization (if any)
Emergency room
Hospitalization more than 24 hours
Future major medical anticipated
36. EMPLOYER Legal name
37. EMPLOYER DBA name (if different)
38. Mailing address
39. Employer FEIN
40. Unemployment ID #
City
State
Zip Code
41. Employer’s contact name and phone #
42. Physical address (if different)
43. Witness (name and phone) - if more than 1 attach a separate sheet
City
State
Zip Code
44. NAICS code
45. Date form completed
46. INSURER name
51. CLAIMS ADMIN COMPANY (CA) name (check one)
Insurer
TPA
47. Insured legal name and FEIN
52. CA address
48. Policy # (including effective dates) or self-insured certificate #
City
State
Zip Code
49. Insurer FEIN
50. Date insurer received notice
53. CA FEIN
54. CA claim #
55. To be completed
Claim type code:
Type of loss code:
Late reason code:
Salary paid in lieu of comp?
Death result of injury?
by the CA:
MN FR01 (12/12)
Employer: Send copies to Insurer (or Workers’ Compensation Division if no insurer), employee, and employee’s union (if applicable)

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