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West Virginia Workers’ Compensation

Form OIC-WC-2

Employers’ Report of Occupational Injury or Disease

PLEASE PRINT OR TYPE

Section I

Employer Information

Insurer:

Third-Party Administrator:

Employer’s Name:

Nature of Business:

FEIN:

Address:

City:

State:

Zip:

Telephone: (

)

Section II

Employee Information

Name: (Last):

(First):

(M.I.):

Occupation/Job Title:

Address:

Telephone: (

)

City:

State:

Zip:

Social Security No.:

Date of Birth:

6. Sex:

Marital Status:

Injured Employee is (check all that apply):

Full-Time

Part-Time

Volunteer

Employee’s Occupation/Job Title:

Owner/Partner

Officer

Retired – Date Retired:

Section III

Information Regarding Injury or Disease

Date of Injury or Last Exposure:

Time:

a.m.

p.m.

Witnesses to Injury:

Date Employer Notified of Injury

Supervisor to whom Injury or Disease

or Disease:

Reported:

If Injury was Fatal, Indicate Date of Death:

Did Injury Occur on Employer’s Property?

Yes

Address or location where injury

occurred:

What was the Employee Doing when Injury Occurred (loading truck, walking down stairs, etc.):

How did the Injury or Disease Occur (be specific; include time that employee began work on the date of injury, any equipment, tools, substances or

objects connected to the injury; attach additional sheet if necessary):

Nature of Injury or Disease (cut, bruise, strain, etc.):

Body Part(s) Injured:

Are You Aware of, or Do You Suspect, a Prior Injury to this Body Part?

Yes

Do You Have Reason to Question this Injury?

Yes

(If “yes,” attach a specific explanation to this form).

Location of Initial Treatment:

Emergency Room?

Yes

Hospitalized?

Yes

Section IV

Wage and Lost Time Information

Date Hired:

Last Day Worked After Occupational Injury or Disease:

Number of Work Days Lost:

Date of Return to Work:

Hours Worked per Week:

Is Light Duty Available?

Yes

Wage on Date of Injury: $

per

hour

day

week

month

Are Wages Being Paid to Injured Employee

If Employee has Returned to Work, is it Alternative or Modified Work?

Yes

During Disability?

Yes

If “yes,” indicate current wage: $

per

hour

day

week

month

Daily rate of pay on the date of injury: $

and best quarter wages of preceding four quarters $

I certify the statements and answers set forth in this section are true and correct to the best of my knowledge. I am aware the law, specifically West

Virginia Code §61-3-24e, provides for severe penalties if I knowingly certify a false report or statement and/or withhold a material fact regarding any

information requested. I acknowledge the provisions of the aforementioned code and the severe penalties for knowingly with fraudulent intent aiding or

abetting anyone in securing or attempting to secure benefits to which he or she is not entitled.

Print Name:

Title:

Signature:

_____________________________________________

Date:

_______/________/________