WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS 
                                          Employer (Name & Address incl. zip)                                     Carrier/Administrator Claim Number                         Report Purpose Code 
                                                                                                                                                                                   
                                                                                                                  Jurisdiction          Jurisdiction Claim No. 
                                                                                                                                                                     
                                                                                                                  Insured Report No. 
                                                                                                                        
                                                                                                                  Employer’s Location Address (if different)                                           Location No. 
                     General                                                                                                                                                                                 
                                                                                                                   
                                          NAICS Code                       Employer FEIN                                                                                                               Phone No. 
                                                                                                                                                                                                             
                                          Carrier (Name, Address & Phone Number)                                  Policy Period                                    Claims Admin (Name, Address & Phone Number) 
                                                                                                                                                                    
                                                                                                                  To                                                     
                                                                                                                        
                                                                                                                               Check if 
                                                                                                                               self 
                                                                                                                               insured 
                                          Carrier FEIN                     Policy Number or Self-Insured Number                                                    Administrator FEIN 
                                                                                                                                                                         
                     Carrier/Claims Admin Agent Name & Code Number 
                                                
                                          Legal Name (Last, First, Middle)            Birth Date       Social Security Number           Date Hired                                          State of Hire 
                                                                                                                                                                                                  
                                          Address (Incl. Zip)                                  Sex            Marital Status            Occupation/Job Title 
                                                                                               Male                Unmarried/                 
                                                                                                                   Single/Div. 
                                                                                               Female              Married              Employment Status 
                                                                                               Unknown             Separated                  
                     Employee             Phone                                       No. of Dependents            Unknown              NCCI Class Code 
                                                                                                                                              
                                          Wage Rate                        Day                 Month         # Days Worked/WK           Full Pay for Date of Injury?                          Yes              No 
                                          $                                Week                Other         # Hrs Worked per Day       Did Salary Continue?                                  Yes              No 
                                                                                                                  
                                          Time Employee         AM         Date of Injury  Time                   AM    Last Work Date                               Date Employer Notified Date Disability 
                                          Began Work            PM         or Illness      Occurred               PM                                                                        Began 
                                                                                                                                                                                                  
                                          Employer Contact Name/Phone Number                                 Type of Illness/Injury                                        Part of Body Affected 
                                                                                                                                                                                 
                                          Did Injury/Illness Exposure Occur on Employer’s      Yes           Type of Illness/Injury Codeype of Illness/Injury Code         Part of Body Affected Code 
                                          Premises?                                            No                                                                                
                                                
                                          Department or location where accident or illness exposure occurred       All Equipment, Materials, or Chemicals Employee Using upon Occurrence 
                                                                                                                         
                     Occurrence           Specific Activity Employee Engaged in at Time of Occurrence              Work Process the Employee Was Engaged in at Time of Occurrence 
                                                                                                                         
                                          How injury or illness/abnormal health condition occurred. Describe the sequence of events and include any objects or substances                   Cause of Injury 
                                          that directly injured the employee or made the employee ill.                                                                                      Code 
                                                                                                                                                                                                  
                                          Date Returned to Work               If Fatal, 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 
                                                                                                                                                                           0            No Medical Treatment 
                                                                                                                                                                           1            Minor: By Employer 
                                                                                                                                                                           2            Minor Clinic/Hosp 
                     Treatment                                                                                                                                             3            Emergency Care 
                                                                                                                                                                           4            Hospitalized – 24 hr. 
                                          Signature of Injured Employee, or Signature on File,         Witness to Accident (Name & Phone Number)                           5            Anticipated Major Med/Lost 
                                          Date                                                                                                                                        Time 
                                                                                                                                                                                       
                     Other                Date Administrator Notified          Date Prepared           Preparer’s Name & Title                                             Preparer’s Phone Number 
                                                                                                                                                                                 
Filing this report is not an admission of liability. This report shall not be evidence of any fact stated herein in any proceeding in respect of the injury, 
illness or death on account of which this report is made.  Idaho Industrial Commission, P.O. Box 83720, Boise, ID 83720-0041                                                                      IC Form IA-1 
(08/2013)