Form 801 - Oregon Workers' Compensation Page 3
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5State of Oregon
FEIN of claim administrator:
Workers' and Employer's
Report of Occupational
Insurer claim number:
Complete all items — Failure to do so may delay beneftis
Injury or Disease
1. Worker's legal name (first, m.i., last):
2. Home phone:
3. Date of birth:
4. Social Security number (see back of form):
5. Worker's street, mailing, and e-mail
6. Male
Female
7. Education - grade
8. Hospitalized overnight as inpatient?
address:
Yes
No
completed: (0 – 20)
(If emergency room - only, mark "No")
9. Nature of injury/disease
10. Name and city of hospital:
(strain, cut, bruise, etc.):
City
State
ZIP
12. Name and address of health insurance
11. Body part(s) affected:
Left
provider:
Right
13.
14. Time of injury:
15. Has body part been injured before?
16.
Date of injury/disease:
Full name, address, and phone of attending
(If yes, explain)
physician:
:
a.m.
p.m.
Yes
No
17. Describe accident fully (please print):
Witness(es):
18. By my signature I am giving NOTICE OF CLAIM and authorizing medical providers and other custodians of claim records to release relevant
medical records. I certify that the above information is true to the best of my knowledge and belief (see paragraphs 3 and 4 on the back). By my
signature, I also authorize the use of my SSN as described in paragraph 2 on the back. (If you do not authorize the use of your SSN as described
in paragraph 2, check here
.)
Worker: Sign and give form to your employer for completion
X
19. Employer's legal business name:
20. Employer BIN:
Worker signature
Date
Employer: Complete items 24-27 only if worker is a leased employee.
Dept. use
Emp no
24. Client's legal business name:
25. Client BIN:
21. Employer's street and e-mail address:
22. Employer FEIN:
Ins no
City
State
ZIP
23. Insurer Policy #:
26. Client's street and e-mail
27. Client FEIN:
address:
Occ
28. Nature of business:
29. Worker class code:
City
State
ZIP
Nature
30. Worker's occupation (do not abbreviate):
31. Is worker owner or
32. Address of injury site if different from 21 or 26:
corp. officer?
Yes
No
Part
33. Date employer first knew of claim:
34. If fatal, date of death
City
State
ZIP
35. Date of hire:
36. State of hire:
37. Injured on employer's or client's premises?
Yes
No
Unknown
Event
38. Did injury occur during course of job?
Yes
No
Unknown
39. Date left work:
40. Time left work:
41 Date returned to regular work:
Source
:
a.m.
p.m. 42. Date returned to work with restrictions/light duty:
Assoc
43. Working
:
44. No. of hours worked per
45. If returned to work with restrictions,
from
a.m.
p.m.
>
object
shift:
shift:
a.m.
p.m.
:
to
were full wages paid?
Yes
No
Insurer use
46. Wage and wage period:
47. If wage varies or includes other earnings
give
Hr.
Day
(tips, room and board, commission, etc.)
$
per
total weekly wage and explain
:
Wk.
Mo.
Yr.
(Attach payroll records for last 52 weeks prior to date of injury)
$
49. No. of days
48. Scheduled days off:
worked per week:
S
S
M
T
W
T
F
50. Department and location where event
51. All equip., materials, or chemicals employee was using when event
occurred:
occurred:
52. Specific activity the employee was engaged in when event occurred.
(Indicate if activity was part of normal job duties):
53.
How injury or illness occurred; describe the sequence of events and include any objects or substances that directly injured the employee or
made the employee ill:
54. Was accident caused by person
(other than
55. Were other workers injur-
56. Is worker "premium exempt"
(a Preferred Worker)?
or by failure of machinery or
injured worker)
ed in the accident?
Yes
No
product?
Yes
No
Yes
No
(If "Yes," attach copy of eligibility card.)
57. Signature of employer representative:
58. Print name, title and phone:
59. Date:
X
Attention: Fatalities must be reported to DCBS/OR-OSHA
within eight hours of occurrence. Accidents resulting in
801
overnight hospitalization with medical treatment must be reported within 24 hours of employer notification
to the DCBS/OR-OSHA
local field office. Report fatalities or accidents by calling (503) 378-3272.
After 5 p.m., before 8 a.m., and on holidays and
weekends, report by calling Oregon Emergency Response, (800) 452-0311.
Original and copy to insurer within 5 days of notice of claim;
copy to worker immediately as receipt of claim;
copy to employer's file.
440-801 (1/00)
WC 8468b (1-00)
UNIFORM INFORMATION SERVICES, INC.
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