Dwc Form-1 - Employers First Report Of Injury Or Illness - 2005

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Send the specified copies to
Deep East Texas Self Insurance Fund
and the injured employee.
CLAIM # ______________________________________
*Employers – Do not send this form to the Texas Department of
Insurance, Division of Worker’s Compensation unless the Division
specifically requests a direct filing.
CARRIER'S CLAIM # ___________________________________________
EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS
1. Name (Last, First, M.I.)
2. Sex
15. Date of Injury (m-d-y)
16. Time of Injury
17. Date Lost Time Began (m-d-y)
F
M
-
-
:
am
pm
3. Social Security number
4. Home Phone
5. Date of Birth (m-d-y)
18. Nature of Injury*
19. Part of Body Injured or Exposed*
-
-
(
)
-
-
6. Does the Employee Speak English?
If No, Specify Language
20. How and Why Injury/Illness Occurred*
YES
NO
7. Race
8. Ethnicity
21. Was employee
22. Worksite Location of Injury (stairs, dock, etc.)*
doing his
YES
White
Black
Asian
Hispanic
Native American
Other
regular job?
NO
9. Mailing Address
Street or P.O. Box
23. Address Where Injury or Exposure Occurred Name of business if incident
occurred on a business site
Street or P.O. Box
County
City
State
Zip Code
County
10. Marital Status
City
State
Zip Code
Married
Widowed
Separated
Single
Divorced
11. Number of Dependent Children
12. Spouse's Name
24. Cause of Injury(fall, tool, machine, etc.)*
13. Doctor's Name
25. List Witnesses
14. Doctor's Mailing Address (Street or P.O. Box)
26. Return to work
27. Did employee
28. Supervisor's
29. Date Reported
date/or expected
die?
Name
(m-d-y)
(m-d-y)
City
State
Zip Code
YES
NO
-
-
30. Date of Hire
31. Was employee hired or recruited in Texas?
32. Length of Service in Current Position
33. Length of Service in Occupation
(m-d-y)
YES
NO
-
-
Months_
Years
Months
Years
34. Employee Payroll Classification Code
35. Occupation of Injured Worker
36. Rate of Pay at this Job
37. Full Work Week is:
38. Last Paycheck was:
39. Is employee an Owner, Partner,
or Corporate Officer?
$
for
Hours or
Days
$
Hourly$
Hours
Days
YES
NO
Weekly
40. Name and Title of Person Completing Form
41. Name of Business
Larry Merrill, Manager of Benefits
Collin County Community College District
42. Business Mailing Address and Telephone Number
43. Business Location (If different from mailing address)
Street or P.O. Box
Telephone
Number and Street
rd
3452 Spur 399, 3
Fl.
972
548-6664
(
)
City
State
Zip Code
City
State
Zip Code
McKinney
TX
75069
44. Federal Tax Identification
45. Primary North American Industry Classification
46. Specific NAICS Code
47. Texas Comptroller Taxpayer No.
Number
61121
8222
999929184
(6 digit)
System Code:(6 digit)
75-2037156
48. Workers' Compensation Insurance Company
49. Policy Number
Deep East Texas Self Insurance Fund
0225
50. Did you request accident prevention services in past 12 months?
YES
NO
If yes, did you receive them?
YES
NO
51. Signature and Title (READ INSTRUCTIONS ON INSTRUCTION SHEET BEFORE SIGNING)
X
Date __
___
DIVISION OF WORKERS’ COMPENSATION
DWC FORM-1 (Rev. 10/05) Page 3

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