IOWA WORKER'S COMPENSATION - FIRST REPORT OF INJURY

EMPLOYER:

Employer Name

Address

City

State

Zip

Employer FEIN

Employer Contact Name

Phone Number

EMPLOYEE:

Employee Name

Date of Birth

Gender  Male   Female

Tax Filing StatusSingle(A)                                Married/Filing Joint(C)

                         Single/Head of Household(B)  Married/Filing Separate

Address

City

State

Zip

Date of Hire

Educational Level (grade completed)

Phone Number

Occupation Description

Department where Regularly worked

Employment Status (check one)

Piece Worker                          Volunteer

Seasonal                                  Apprenticeship/Full-Time

Regular Employee/Full Time     Apprenticeship/Part-Time

Part-Time                                Other

Employee ID Number   (check one)

ID #

Social Security Number

Employment VISA Number

Passport Number

Green Card

Employee ID Assigned by Jurisdiction

Marital Status:  (check one)

Unmarried (U)

Married (M)

Separated (S)

Employee's Authorization to Release the Following:

Medical Records  yes     no

Social Security Number  yes   no

Wage:

Average Wage $ (check one):

hourly        daily        semi-monthly        monthly

bi-weekly    annual    weekly

Number of Days Regularly Worked Per Week:

Salary Continued in Lieu of Compensation: yes     no

Full Wages Paid for Date of Injury:   yes    no

Discontinued Fringe Benefits $

Employee Number of Dependents:

Employee Number of Exemptions (check one)

Entitled            Withholding

Accident/Injury:

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)

Employee Date of Death (if applicable)

Time of Injury

Time Employee Began Work

Pre-Existing Disability Code:

yes        no        Unknown

Accident Premises Code:

Employer (E)    Lessee (L)    Other (X)

Accident Site Organization Name:

Accident Site Address:

City

State

Zip

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

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

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

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

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:

Witness Name

Phone Number

Medical:

Initial Treatment Code:    (check one)

no medical treatment (0)

minor/on-site treatment (1)

clinic/hospital visit(2)

emergency care (3)

hospitalization>24 hours(4)

future medical treatment/lost time anticipated (5)

Initial Medical Provider Name:

Address:

City

State

Zip

Preparer's Name

Title

Phone Number

Date