Form Ia-1 - Workers Compensation-First Report Of Injury Or Illness

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WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS

Employer (Name & Address incl. zip)

Carrier/Administrator Claim Number

Report Purpose Code

Jurisdiction

Jurisdiction Claim No.

Insured Report No.

Employer’s Location Address (if different)

Location No.

NAICS Code

Employer FEIN

Phone No.

Carrier (Name, Address & Phone Number)

Policy Period

Claims Admin (Name, Address & Phone Number)

Check if

self

insured

Carrier FEIN

Policy Number or Self-Insured Number

Administrator FEIN

Agent Name & Code Number

Legal Name (Last, First, Middle)

Birth Date

Social Security Number

Date Hired

State of Hire

Address (Incl. Zip)

Sex

Marital Status

Occupation/Job Title

Male

Unmarried/

Single/Div.

Female

Married

Employment Status

Unknown

Separated

Phone

No. of Dependents

Unknown

NCCI Class Code

Wage Rate

Day

Month

Full Pay for Date of Injury?

Yes

# Days Worked/WK

# Hrs Worked per Day

Week

Other

Did Salary Continue?

Yes

Time Employee

Date of Injury

Time

Last Work Date

Date Employer Notified

Date Disability

Began Work

or Illness

Occurred

Began

Employer Contact Name/Phone Number

Type of Illness/Injury

Part of Body Affected

Did Injury/Illness Exposure Occur on Employer’s

Yes

Type of Illness/Injury Code

ype of Illness/Injury Code

Part of Body Affected Code

Premises?

Department or location where accident or illness exposure occurred

All Equipment, Materials, or Chemicals Employee Using upon Occurrence

Specific Activity Employee Engaged in at Time of Occurrence

Work Process the Employee Was Engaged in at Time of Occurrence

How injury or illness/abnormal health condition occurred. Describe the sequence of events and include any objects or substances

Cause of Injury

that directly injured the employee or made the employee ill.

Code

Date Returned to Work

If Fatal, Date of Death

Were Safeguards or Safety Equipment Provided?

Yes

Were they used?

Yes

Physician/Health Care Provider (Name & Address)

Hospital (Name & Address)

Initial Treatment

No Medical Treatment

Minor: By Employer

Minor Clinic/Hosp

Emergency Care

Hospitalized – 24 hr.

Signature of Injured Employee, or Signature on File,

Witness to Accident (Name & Phone Number)

Anticipated Major Med/Lost

Date

Time

Preparer’s Name & Title

Preparer’s Phone Number

Date Administrator Notified

Date Prepared

Filing this report is not an admission of liability. This report shall not be evidence of any fact stated herein in any proceeding in respect of the injury,

illness or death on account of which this report is made. Idaho Industrial Commission, P.O. Box 83720, Boise, ID 83720-0041

IC Form IA-1

(08/2013)