First Report of Employee Injury Form

* = Required Information

1. Employee Social Security Number *

2. OSHA Case Number *

3. Date Of Claimed Injury *

4. Time of injury

Time of injury

5. Time employee began work on date of injury

Time employee began work on date of injury

6. Employee Name (Last, First, Middle) *

7. Gender

Male

Female

8. Marital Status

Married

Unmarried

9. Home address *

10. Home phone #

11. Date of birth

City

State

Zip Code

12. Occupation

13. Regular Department

14. Date Hired

15. Average Weekly Wage

16. Rate Per Hour

17. Hours Per Day

18. Days Per Week

19. Employment Status

Full time

Part time

Seasonal

Volunteer

20. Weekly Value Of:

Meals

Lodging

2nd Income

21. Apprentice

Yes

22. Tell us how the injury occurred and what the employee was doing before the incident (give details) Examples: "Worker was driving lift truck with a pallet of boxes when the truck tipped, pinning worker's left leg under drive shaft." "Worker developed soreness in left wrist over time from daily computer key entry."

23. What was the injury or illness (include the part(s) of body)? Examples:chemical burn left hand, broken left leg, carpal tunnel syndrome in left wrist.

24. What tools, equipment, machines, objects, or substances were involved? Examples: chlorine, hand sprayer, pallet lift truck, computer keyboard.

25. Did injury occur on employer's premises?

Yes

If no, indicate name and address of place of occurrence

26. Date of first day of any lost time

27. Employer paid for lost time on day of injury (DOI)

Yes

No lost time on DOI

28. Date employer notified of injury

29. Date employer notified of lost time

30. Return to work date

31. Date of death

32. Treating Physician

Name

Address

Phone

33. Hospital/Clinic

Name (if any)

Address (if any)

34. Emergency Room Visit

Yes

35. Overnight in-patient

Yes

36. Employer Legal Name

37. Employer DBA name (if different)

38. Mailing Address

City

State

Zip Code

39. Employer FEIN

40. Unemployment ID #

41. Employer's contact name and phone

42. Physical Address (if different)

City

State

Zip Code

43. Witness Name

43. Witness Phone

44. NAICS code

45. Date form completed

INSURER

46. Insurer Name

47. Insured Legal Name

48. Policy # or self-insured certificate #

49. Insurer FEIN

50. Date Insurer Received Notice

CLAIMS ADMIN

51. Claims Admin Company Name

Claims Admin Company Type

52. CA Address

CA City

CA State

CA Zip Code

53. CA FEIN

54. Claim #

GENERAL INSTRUCTIONS TO THE EMPLOYER

Filing this form is not an admission of liability. You must report a claim to your insurer whenever anyone believes that a work-related injury or illness that requires medical care or lost time from work has occurred. If the claimed injury wholly or partially incapacitates the employee for more than three calendar days, the claim must be made on this form and reported to your insurer within ten days. Your insurer may require you to file it sooner. Failure to file within the ten days may result in penalties. Self-insured employers have 14 days to file this form with the Department of Labor and Industry (Department). It is important to file this form quickly to allow your insurer time to investigate the claim. Your insurer will forward a copy of this form to the Department, if necessary.

If the claim involves death or serious injury (including injuries that later result in death), you must notify the Department and your insurer within 48 hours of the occurrence. The claim can be reported initially to the Department by telephone (651-284-5041), fax (651-284-5731), or personal notice. The initial notice must be followed by the filing of this form within seven days of the occurrence.

Employers are required to complete this form. Each piece of information is needed to determine liability and entitlement to benefits. Failure to complete the form may result in delayed processing and possible penalties. You must file this form with your insurer, and give a copy to the employee and the employee’s local union office. You are required to provide the employee with a copy of the Employee Information Sheet, which is available on the Department’s web site at www.doli.state.mn.us. Employees are not responsible for completing this form.

INSTRUCTIONS TO THE INSURER/CLAIMS ADMINISTRATOR/SELF-INSURED EMPLOYER

The following data elements must be completed on this form prior to filing with the Department of Labor and Industry: employee’s name and social security number; date of injury; and the names of the employer and insurer. If any of this information is missing, the First Report will be rejected and returned to you (per Minn. Stat. § 176.275). Providing the name of the third party administrator does not meet the statutory requirement to provide the name of the insurer. NOTE: If the claim does not involve lost time beyond the waiting period or potential PPD, the form does NOT need to be filed with the Department.

1. Item 46: Fill in the name of the insurance company. If the employer is self-insured, indicate the name of the licensed or public self-insured company or group.

2. Items 47-48: Fill in the legal name of the employer who purchased the policy from the insurer (named in Item 46) and the policy number. If the employer is licensed to self-insure, fill in the certificate number.

3. Item 49: Fill in the insurer’s Federal Employment ID number (FEIN) number.

4. Item 51: Fill in the name and address of the company administering the claim (either the insurer or third party administrator). Be sure to mark either the “Insurer” or “TPA” box.

5. Item 53-54: Fill in the claims administrator’s FEIN and claim number.

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800- 342-5354 (DIAL-DLI)/ Voice or TDD (651) 297-4198.

ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

SUPERVISOR'S INCIDENT REPORT

Incident Type

Injury (work related)

Illness (work related)

Property Damage

Incident

Employee Name (First, Middle, Last) *

Social Security Number *

Sex

Male

Female

Employee Home Telephone Number

Employee's Street Address *

City

State

Zip Code

Age

Birthdate

Job Title

Department

Employee's Scheduled Work Week When Injured

Start Time

End Time

Hours Per Day

Hours Per Week

Days Per Week

Normal Full-Time Schedule for Injured's Work

Start Time

End Time

Injury Date

Hour of Day

Last Day Worked

Start Date

No Lost Time

Date Returned to Work

Estimated Date of Return

Did employee seek medical attention?

Yes

If yes, name of treating physician

Name of clinic or hospital

Will the employee complete a drug screening?

Yes

Names of Witness (Attach Witness Statement)

Injured Employee's statement of what happened. (Identify circumstances and equipment involved.)

How could this incident have been prevented?

What corrective action has been taken?

What is the injury/illness? (Be specific.)

I believe that the answers to the above questions are true to the best of my knowledge.

Employee's Signature

Date

Supervisor's Signature

Date

Notified

EMPLOYEE INCIDENT REPORT

Employee Name*

Facility

Incident Date

Incident Time

Date Supervisor Notified

Exact Body Part Injured

Describe What Happened

What do you think caused your incident?

What do you think could be done to prevent this type of incident from occurring again?

Employee Name

Date Report Completed

Eye	Head
Neck	Back
Arm	Shoulder
Fingers	Leg
Knee	Hip
Foot	Wrist
Hand	Toes
Ankle	Elbow
Trunk (Other than back)	Other