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                                                        INSTRUCTIONS

General Instructions:

1. Please enter information into all of the areas of the First Report form, except the boxes at the top right corner of the form which is for
office use only.
2. Enter all dates in MM/DD/YY format.
3. Please return completed form electronically by an approved EDI process.
4. For answers to questions, please call (317) 232-3808.

Definitions:

AGENT NAME AND CODE NUMBER: Enter the name of your insurance agent and his / her code number if known. This information
can be found on your insurance policy.
ALL EQUIPMENT, MATERIALS OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR EXPOSURE OCCURRED: List
anything the employee was using, applying, handling or operating when the injury or exposure occurred. If the injury involves a fall, indicate
any surfaces and / or objects the claimant fell on and where they fell from. Enter “NA” if no equipment, materials or chemicals were being
used (e.g. Acetylene cutting torch, metal plate, etc.).
AVG WG/WK: Claimant’s average weekly wage, calculated by totaling the latest 52 weeks of wages (including overtime, tips, etc.) and
dividing by 52.
CLAIMS ADMINISTRATOR: Enter the name of the carrier, third-party administrator, state fund, or self-insured responsible for administering
the claim.

CONTACT NAME / TELEPHONE NUMBER: Enter the name of the individual at the employer’s premises to be contacted for additional
information (i.e. Supervisor, HR Person, Nurse, etc.)
DATE DISABILITY BEGAN: The first day on which the claimant originally lost time from work due to the occupational injury or disease
or as otherwised deigned by statute.
DEPARTMENT OR LOCATION WHERE ACCIDENT OR EXPOSURE OCCURRED: If the accident or exposure did not occur on the
employer’s premises, enter address or location. Be specific (e.g. Maintenance, Client’s Office, Cafeteria, etc.).
EMPLOYEE STATUS: Indicate the employee’s work status from the following choices: Full-time, Part-time, Apprentice Full-time, Apprentice
Part-time, Volunteer, Seasonal Worker, Piece Worker, On-Strike, Disabled, Retired, Not Employed or Unknown (you may also abbreviate
the above as: (FT, PT, AFT, APT, VO, SW, PW, OS, DI, RE, NE, or UK).
HOW INJURY / ILLNESS OCCURRED: Describe the sequence of events leading to the injury or exposure (e.g. Worker stepped back
to inspect work and slipped on some scrap metal. As worker fell, he brushed against the hot metal; Worker stepped to the edge of the
scaffolding, lost balance and fell six feet  to the concrete floor. The worker’s right wrist was broken in the fall).
NCCI CLASS CODE: A four-digit code classifying the occupation of the claimant.
OCCUPATION / JOB TITLE: Enter the primary occupation of the claimant at the time of the accident or exposure.
PART OF BODY AFFECTED: Indicate the part of body affected by the injury / illness (e.g. Right forearm, Low Back, etc.)
REPORT PURPOSE CODE: 00 = Original First Report of Injury; 02 = Updated or Amended First Report.
RTW DATE (Return to Work Date): Enter the date following the most recent disability period on which the employee returned to work.
SIC CODE: This is the code which represents the nature of the employer’s business which is contained in the Standard Industrial
Classification Manual published by the Federal Office of Management and Budget.
SPECIFIC ACTIVITY EMPLOYEE ENGAGED IN DURING ACCIDENT / EXPOSURE: Describe the specific activity the employee was
engaged in during the accident or exposure (e.g. Cutting metal plate for flooring, sanding ceiling woodwork in preparation for painting).
TYPE OF INJURY / ILLNESS: Briefly describe the nature of the injury or illness (e.g. Contusion, Laceration, Fracture, etc.)
WORK PROCESS THE EMPLOYEE WAS ENGAGED IN DURING ACCIDENT / EXPOSURE: Enter “NA” if employee was not engaged
in a work process, such as if walking down the hallway (e.g. Building maintenance).



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                                                                                                                                                        Reset Form
         INDIANA WORKER’S COMPENSATION                                                                          FOR WORKER’S COMPENSATION BOARD USE ONLY
         FIRST REPORT OF EMPLOYEE INJURY, ILLNESS                                                   Jurisdiction              Jurisdiction claim number      Process date
         State Form 34401 (R10 / 1-02)
         Please return completed form electronically by an approved EDI process.                                 PLEASE TYPE or PRINT IN INK
NOTE: Your Social Security number is being requested by this state agency in order to pursue its statutory responsibilities. Disclosure is voluntary and you will
            not be penalized for refusal.
                                                                           EMPLOYEE INFORMATION
Social Security number         Date of birth      Sex                                             Occupation / Job title                    NCCI class code
                                                        Male          Female     Unknown
Name (last, first, middle)                                                 Marital status         Date hired                  State of hire Employee status
                                                                             Unmarried
                                                                                                  Hrs / Day     Days / Wk     Avg Wg / Wk
Address (number and street, city, state, ZIP code)                           Married                                                                    Paid Day of Injury
                                                                             Separated                                                                  Salary Continued
                                                                             Unknown
                                                                                                  Wage          Per
Telephone number (include area                                             Number of dependents   $                           Hour          Day         Week     Month
                                                                                                                              Year          Other
                                                                           EMPLOYER INFORMATION
Name of employer                                                           Employer ID#                         SIC code                    Insured report number

Address of employer (number and street, city, state, ZIP code)             Location number                      Employer’s location address (if different)

                                                                           Telephone number

                                                                           Carrier / Administrator claim number OSHA log number             Report purpose code

Actual location of accident / exposure (if not on employer’s premises)

                                                        CARRIER / CLAIMS ADMINISTRATOR INFORMATION
Name of claims administrator                                                       Carrier federal ID number    Check if appropriate
                                                                                                                                                   Self Insurance
Address of claims administrator (number and street, city, state, ZIP code)                                      Policy / Self-insured number
                                                                                           Insurance Carrier
Telephone number                                                                           Third Party Admin.   Policy period
                                                                                                                         From                    To
Name of agent                                                              Code number

                                                             OCCURRENCE / TREATMENT INFORMATION
Date of Inj./ Exp.             Time of occurrence       AM     PM          Date employer notified Type of injury / exposure                                  Type code
                                             Cannot be determined
Last work date                 Time workday began            Date disability began                Part of body                                               Part code

RTW date                       Date of death                 Injury / Exposure occurred    Yes      Name of contact                         Telephone number
                                                             on employer’s premises?       No
Department or location where accident / exposure occurred                                         All equipment, materials, or chemicals involved in accident

Specific activity engaged in during accident / exposure                                           Work process employee engaged in during accident / exposure

How injury / exposure occurred. Describe the sequence of events and include any relevant objects or substances.
                                                                                                                                            Cause of injury code

Name of physician / health care provider

Hospital or offsite treatment (name and address)                                                                                            INITIAL TREATMENT
                                                                                                                                            No Medical Treatment
                                                                                                                                            Minor: By Employer
                                                                                                                                            Minor: Clinic / Hospital
Name of witness                                              Telephone number                     Date administrator notified               Emergency Care
                                                                                                                                            Hospitalized > 24 Hours
Date prepared                  Name of preparer                            Title                    Telephone number                        Future Major Medical / Lost
                                                                                                                                            Time Anticipated
An employer’s failure to report an occupational injury or illness may result in a $50 fine (IC 22-3-4-13).






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