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

         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 (R9 / 3-01)
         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 code)                                 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                           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                Date employer notified             Type of injury / exposure                                  Type code
                                            AM      PM
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                                                                                                  INITIAL TREATMENT
                                                                                                                                          No Medical Treatment
                                                                                                                                          Minor: By Employer
Name of witness                                              Telephone number                   Date administrator notified               Minor: Clinic / Hospital
                                                                                                                                          Emergency Care
Date prepared              Name of preparer                                Title                  Telephone number                        Hospitalized > 24 Hours
                                                                                                                                          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).