MWCC - WORKERS’ COMPENSATION - FIRST REPORT OF INJURY OR ILLNESS
 EMPLOYER (NAME & ADDRESS INCL ZIP)                    CARRIER/ADMINISTRATOR CLAIM NUMBER                                     REPORT PURPOSE CODE

                                                       JURISDICTION                                 JURISDICTION CLAIM NUMBER

                                                      INSURED REPORT NUMBER

                                                       EMPLOYER’S LOCATION ADDRESS (IF DIFFERENT)                              LOCATION #
  SIC CODE            EMPLOYER FEIN                                                                                            PHONE #

   CARRIER/CLAIMS ADMINISTRATOR
 CARRIER (NAME, ADDRESS & PHONE NO)                    POLICY PERIOD                                CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO)
                                                                       TO
                                                          CHECK IF APPROPRIATE
                                                             SELF INSURANCE
  CARRIER FEIN                       POLICY/SELF-INSURED NUMBER                                                            ADMINISTRATOR FEIN

  AGENT NAME & CODE NUMBER
  EMPLOYEE/WAGE
 NAME (LAST, FIRST, MIDDLE)                            DATE OF BIRTH                     SOCIAL SECURITY NUMBER            DATE HIRED       STATE OF  HIRE

  ADDRESS (INCL ZIP)                                   SEX                                MARITAL STATUS                    OCCUPATION/JOB TITLE
                                                              MALE (M)                      UNMARRIED/SINGLE/DIVORCED (U)
                                                              FEMALE (F)                    MARRIED (M)                     EMPLOYMENT STATUS

                                                              UNKNOWN (U)                   SEPARATED (S)
  PHONE                                               # OF DEPENDENTS                                                       NCCI CLASS CODE
                                                                                            UNKNOWN (K)
  RATE               PER:            DAY    MONTH     #DAYS WORKED WEEK                              FULL PAY FOR DAY OF INJURY?              YES            NO
                                            OTHER:                                                   DID SALARY CONTINUE?                     YES            NO
                                    WEEK
  OCCURRENCE/TREATMENT
  TIME EMPLOYEE                       AM   DATE OF INJURY/ILLNESS   TIME OF             AM  LAST WORK DATE  DATE EMPLOYER NOTIFIED  DATE DISABILITY BEGAN
BEGAN WORK                                                  OCCURRENCE
                                      PM                                                PM
  CONTACT NAME/PHONE NUMBER                                   TYPE OF INJURY/ILLNESS                         PART OF BODY AFFECTED

  DID INJURY/ILLNESS EXPOSURE OCCUR ON EMPLOYER’S PREMISES?   TYPE OF INJURY/ILLNESS CODE                    PART OF BODY AFFECTED CODE
                                      YES   NO
  COUNTY WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED                                      ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT       
                                                                                        OR ILLNESS EXPOSURE OCCURRED

  SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS               WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS               
EXPOSURE OCCURRED                                                                       EXPOSURE OCCURRED

  HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT
  DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL                                                                       CAUSE OF INJURY CODE

  DATE RETURN(ED) TO WORK             IF FATAL, GIVE DATE OF DEATH   WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED?                            YES            NO
                                                              WERE THEY USED?                                                                 YES            NO
  PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS)             HOSPITAL (NAME & ADDRESS)                                        INITIAL TREATMENT
                                                                                                                               NO MEDICAL TREATMENT (0) 
                                                                                                                                  MINOR: BY EMPLOYER (1) 
                                                                                                                                  MINOR CLINIC/HOSP (2) 
                                                                                                                                  EMERGENCY CARE (3) 
  WITNESSES (NAME & PHONE #)                                                                                                      HOSPITALIZED > 24 HRS (4) 
                                                                                                                             FUTURE MAJOR MEDICAL/      
                                                                                                                               LOST TIME ANTICIPATED (5) 
  DATE ADMINISTRATOR NOTIFIED  DATE PREPARED          PREPARER’S NAME & TITLE                                                 PHONE NUMBER

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