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WORKERS' COMPENSATION - FIRST REPORT OF INJURY EMPLOYER'S INSTRUCTIONS
GENERAL INFORMATION - State whether employee's salary was continued by the
DID SALARY CONTINUE
EMPLOYER (NAME & ADDRESS INCL ZIP) - The name and address of the entity employer in lieu of compensation benefits.
employing or statutorily responsible for the employee.
SIC CODE - The code which represents the nature of the employer's business which is OCCURRENCE/TREATMENT INFORMATION
contained in the Standard Industrial Classification Manual published by the Federal
Office of Management and Budget. TIME EMPLOYEE BEGAN WORK - The time employee began work on date of
injury.
EMPLOYER FEIN - Employer's Federal Employer Identification Number.
DATE OF INJURY/ILLNESS - The date employee was injured.
CARRIER/ADMINISTRATOR CLAIM NUMBER - Carrier's claim or file number.
TIME OF OCCURRENCE - The time employee was injured.
REPORT PURPOSE CODE - A code used with Electronic Data Interchange to define
the specific purpose of the report. (Original, Cancel, Change, Correction) LAST WORK DATE - The date employee last worked following the injury.
JURISDICTION - State in which you are filing the claim (Mississippi). DATE EMPLOYER NOTIFIED - The date on which the employer was notified of the
injury.
JURISDICTION CLAIM NUMBER - Number assigned to claim by Mississippi
Workers' Compensation Commission (to be completed by MWCC). DATE DISABILITY BEGAN - The date on which employee began losing time.
INSURED REPORT NUMBER - The number, if any, used by the employer to identify CONTACT NAME/PHONE NUMBER - Name and phone number of employer
the claim. representative to be contacted for further information.
EMPLOYER'S LOCATION ADDRESS (IF DIFFERENT) - The name and address TYPE OF INJURY/ILLNESS - Briefly describe the nature of the injury or illness, (e.g.,
of the employer's facility where the employee was employed at the time of injury, if Lacerations to the forearm).
different from above.
PART OF BODY AFFECTED - Indicate the part of body affected by the injury/illness,
LOCATION #/ PHONE # - The number, if any, assigned by the employer to identify its (e.g., Right Forearm, lower back).
location where the injury occurred and the phone number.
DID INJURY/ILLNESS EXPOSURE OCCUR ON EMPLOYER'S PREMISES -
CARRIER (NAME, ADDRESS & PHONE NO) - The licensed business entity issuing Mark yes or no as applicable.
the contract of insurance and assuming financial responsibility for the claim on behalf of
the employer. TYPE OF INJURY/ILLNESS CODE - The NCCI code which corresponds to the
nature of the injury or illness. (NCCI Table 8: Nature of Injury Codes)
POLICY PERIOD - The date that the contract/policy under which the claim occurred
began and expired. PART OF BODY AFFECTED CODE - The NCCI code which corresponds to the part
of the body injured. (NCCI Table 7: Part of Body Codes)
CHECK IF APPROPRIATE (SELF-INSURANCE) - An indicator that identifies the
employer as one who retains the risks arising from their operations and bears the financial COUNTY WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED - The
responsibility. A jurisdictionally approved or acknowledged employer, group fund, or county where the injury occurred. If the injury did not occur in Mississippi, put “out of
association assuming financial risk and responsibility for their employee's worker's state”.
compensation claims.
ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING
CLAIMS ADMINISTRATOR - The business entity providing claim services on behalf WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED - List all of the
of the carrier, or self-insured. The name of the carrier, third party administrator, state equipment, materials, and/or chemicals the employee was using, applying, handling or
fund, or self-insured responsible for administering the claim. operating when the injury or illness occurred. Be specific, for example: decorator's
scaffolding, electric sander, paintbrush, and paint. Enter "NA" for not applicable if no
CARRIER FEIN - Carrier's Federal Employer Identification Number. equipment, materials, or chemicals were being used.
POLICY/ SELF-INSURED NUMBER - The number assigned by the carrier to the SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE
insurance contract/policy for the employer; or any similar number assigned to a self- ACCIDENT OR ILLNESS EXPOSURE OCCURRED - Describe the specific activity
insured employer. the employee was engaged in when the accident or illness exposure occurred, such as
sanding ceiling woodwork in preparation for painting.
ADMINISTRATOR FEIN - Federal Employer Identification Number of Administrator.
WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT
AGENT NAME & CODE NUMBER - The name of the insurance agent and the agent's OR ILLNESS EXPOSURE OCCURRED - Describe the work process the employee
code number if known. This information should be found in the insurance policy. was engaged in when the accident or illness exposure occurred, such as building
maintenance. Enter "NA" for not applicable if employee was not engaged in a work
EMPLOYEE/WAGE INFORMATION process (e.g., walking along a hallway).
HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION
NAME (LAST, FIRST MIDDLE) - Employee's legally recognized name. OCCURRED, DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY
OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE
ADDRESS - The mailing address used by the employee. OR MADE THE EMPLOYEE ILL - Describe how the injury or illness/abnormal
health condition occurred. Include the sequence of events and name any objects or
PHONE - A telephone number where the employee can be reached. substance that directly injured the employee or made the employee ill. For example:
Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six
DATE OF BIRTH - The date the employee was born. feet to the floor. The worker's right wrist was broken in the fall.
SOCIAL SECURITY NUMBER - A number assigned by the Social Security CAUSE OF INJURY CODE - The NCCI code which identifies the cause of injury.
Administration used to identify the employee. (NCCI Table 9: Cause of Injury Codes)
DATE HIRED - The date the injured worker began his/her employment with the DATE RETURN(ED) TO WORK - Enter the date following the most recent disability
employer under which the claim is being filed. If there have been multiple periods of period on which the employee returned to work.
employment, this would be the beginning date of the current employment period.
IF FATAL, GIVE DATE OF DEATH - Date of death of employee.
STATE OF HIRE - State where employee was hired.
WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED/WERE THEY
SEX - The code which indicates the sex of the employee. USED - Check applicable "yes" or "no" box.
MARITAL STATUS - The code which indicates the marital status of the employee. PHYSICIAN/HEALTH CARE PROVIDER (NAME AND ADDRESS) - The name
and address of the physician or health care professional providing initial treatment.
OCCUPATION/JOB TITLE - This is the primary occupation of the employee at the
time of the accident or exposure. HOSPITAL (NAME AND ADDRESS) - The name and address of the hospital where
employee was treated (if applicable).
EMPLOYMENT STATUS - Indicate the employee's work status. The valid choices
are: Full-time, Part-Time, Not Employed, On Strike, Disabled, Retired, Unknown, INITIAL TREATMENT - Check applicable choices.
Apprenticeship Full-Time, Apprenticeship Part-Time, Volunteer, Seasonal, or Piece
Worker. WITNESSES (NAME & PHONE #) - The name(s) and phone number(s) of any one
who witnessed the accident.
NCCI CLASS CODE - A code which corresponds to the primary occupation which the
employee was engaged at the time of accident/injury, or injurious exposure. Codes are DATE ADMINISTRATOR NOTIFIED - The date the carrier or claims administrator
found in the NCCI BASIC MANUAL FOR WORKERS' COMPENSATION AND processing the claim received notice of the injury.
EMPLOYERS LIABILITY INSURANCE.
DATE PREPARED - The date this report was prepared.
RATE - The reported employee's wage rate at the time of injury.
PREPARER'S NAME & TITLE - The name and title of the person who prepared this
# DAYS WORKED/ WEEK - The number of days worked by the employee in a week. report.
FULL PAY FOR DAY OF INJURY - State whether employee was paid his full wages PHONE NUMBER - The phone number of the person who prepared this report.
on the injury date.
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