Form 1.2 - First Report Of Injury Or Illness - Iowa Workers' Compensation

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Iowa Workers’ Compensation – FIRST REPORT OF INJURY OR ILLNESS

Jurisdiction Code______________

Jurisdiction Claim Number_______________

Claim Administrator Name:

Claim Representative Business

Insurer Name

(if different than claim administrator):

Phone Number:

Mailing Address, City, State, & Postal Code:

Claim Administrator Claim Number:

Insurer FEIN:

Claim Administrator FEIN:

Claim Type Code:

Employer Name:

Employer FEIN:

Insured Report Number:

Employer Type Code:

__ Employer (E)

__ Lessor (L)

Physical Address, City, State, & Postal Code:

Mailing Address, City, State, & Postal Code:

Industry Code:

Insured Location Number:

Employer UI Number:

Nature of Business:

Employer Contact Name and Business Phone Number:

Insured Name

Insured FEIN:

Insured Postal Code:

Policy/Contract Number:

Coverage Effective Date:

Self Insurance License/

(parent company if different than employer):

Certificate Number:

Coverage Expiration Date:

Employee Name

Date of Birth:

Gender:

Tax Filing Status

(First, Middle, Last, & Suffix):

(check one):

__ Male (M)

____ Single (A)

____ Married/Filing Joint (C)

Mailing Address, City, State, & Postal Code:

Date of Hire:

__ Female (F)

____ Single/Head of Household (B)

____ Married/Filing Separate(D)

Educational Level

Marital Status:

(grade completed): _______ [GED = 12]

(check one)

Employment Status (

Employee ID Number

check one):

(check one):

___ Unmarried (U)

___ Married (M)

Occupation Description:

____ Social Security Number

___ Separated (S)

____ Employment VISA Number

Employee’s Authorization to

Release the Following:

Manual Classification Code:

____ Passport Number

Medical Records

__ yes

____ Green Card

Department Where Regularly Worked:

____ Employee ID Assigned by Jurisdiction

Social Security Number

__ yes

Average Wage $ ___________

(check one):

Salary Continued In Lieu of Compensation:

___ yes

___ no

Employee Number of Dependents: __________

___ hourly

___ daily

___ semi-monthly

___ monthly

Employee Number of Exemptions: ___________

(check

Full Wages Paid for Date of Injury:

___ yes

___ no

___ bi-weekly

___ annual

___ weekly

one)

___ Entitled

Number of Days Regularly Worked Per Week: _______

Discontinued Fringe Benefits: $_____________

___ Withholding

Describe the nature of the injury. (ex. amputation, burn, cut, fracture):

_____________________ Date of Injury

_____________________ Date Employer Had Knowledge of the Injury

_____________________ Date Claim Administrator Had Knowledge of the Injury

_____________________ Initial Date Last Day Worked

_____________________ Initial Return to Work Date (if applicable)

Part(s) of body directly affected by the injury or illness. (ex. hand, arm, circulatory system):

_____________________ Employee Date of Death (if applicable)

_____________________ Time of Injury

_____________________ Time Employee Began Work

Pre-Existing Disability Code:

Describe the events that caused the injury. (ex. fell, operating machinery, chemical exposure):

___ Yes

___ No

___ Unknown

Accident Premises Code:

___ Employer (E)

___ Lessee (L)

Name the object or substance that directly injured the employee. (ex. knife, floor, acid, oil):

___ Other (X)

Accident Site Organization Name:

Accident Site Street, City, State, & Postal Code:

Specify activity the employee was engaged in when the event occurred. (ex. cutting metal plate for flooring) Indicate if activity was part of normal duties:

Accident Location Narrative

(if no street address):

Accident Site County/Parish:

Witness Name & Business Phone Number:

Initial Treatment Code

Initial Medical Provider Name:

Managed Care Organization Name or ID Number:

(check one):

___ no medical treatment (0)

___ minor/on-site treatment (1)

___ clinic/hospital visit (2)

Initial Medical Provider Physical Address, City, State, & Postal Code: