First Notice of Injury

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State Injury Occurred What is the business name? What is your policy number? If policy number is not available, what is the Federal ID number? Briefly describe the nature of the business: What is your name (first, last)? What is your title? What is your phone number, including area code? What is the injured employee's name? What is the injured employee's social security number? What is injured employee's date of birth? What is the injured employee's home address? (include state, city, and zip code) What is injured employee's home phone number, including area code? Is the injured employee a male or female? Male Female
Marital Status: (Mandatory for CA) What was the date and time of the injury? What is the injured employee's job title or occupation? If applicable, what is the department code? What is the full address of business location injured employee works? (Include, city, state & zip code) Was the employee injured at the location listed above? Yes No
If 'No', provide the full address where the injury did occur?
(Include city, state & zip code) Employment Status: (Mandatory for CA) What is the injured employee's date of hire? Gross Wages: (Mandatory for CA) $ Days Worked Per Week: (Mandatory for CA) Hours Worked Per Day: (Mandatory for CA) What is the injured employee's hourly rate? (Mandatory for CA) $
Pay Period: (Mandatory for CA) What time did the injured employee begin work on the day of injury? Will the injured employee miss time from work? Yes No
If yes, how many days? Days Will the employee be paid in full for the day of injury? Yes No
Salary being continued? (Mandatory for CA) Yes No
What was the last day the injured employee worked due to injury? What date did the injured employee return to work, or is expected to return to work? What date was the injury reported to the employer? What type of injury did the employee sustain? For example, contusions, lacerations, or burns. What body part(s) was affected? How did the accident happen? Was the injury fatal? Yes No
If yes, list the date of death: Did the injured employee seek medical treatment? Yes No
If yes, what type of medical treatment did the injured employee seek? Minor Medical Treatment by Employee
Hospitalization for more than 24 hours
Minor Medical Treatment by Clinic/Hospital
Future major medical/lost time anticipated
Emergency Care

Emergency Care

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