WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS 
   EMPLOYER (NAME & ADDRESS INCL ZIP)                                             CARRIER/ADMINISTRATOR CLAIM NUMBER                              OSHA LOG NUMBER                 REPORT PURPOSE CODE 
                                                                                                                                                                             
                                                                                  JURISDICTION                                                    JURISDICTION CLAIM NUMBER 
                                                                                                                                                                             
                                                                                  INSURED REPORT NUMBER                                                                      
                                                                                                                                                                             
                                                                                  EMPLOYER’S LOCATION ADDRESS (IF DIFFERENT)                                                      LOCATION # 
                                                                                                                                                                             
   INDUSTRY CODE              EMPLOYER FEIN                                                                                                                                       PHONE # 
                                                                                                                                                                             
   CARRIER/CLAIMS ADMINISTRATOR 
   CARRIER (NAME, ADDRESS, & PHONE #)                                             POLICY PERIOD                              CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO)                                             
                                                                                                 TO                                                                                                                     
                                                                                                                                                                                                                        
                                                                                  CHECK IF APPROPRIATE                                                                                                                  
                                                                                        SELF INSURANCE                                                                                                                  
   CARRIER FEIN                             POLICY/SELF-INSURED NUMBER                                                                                             ADMINISTRATOR FEIN                                    
                                                                                                                                                                                                                        
   AGENT NAME & CODE NUMBER                                                                                                                                                                                             
                                                                                                                                                                                                                        
   EMPLOYEE/WAGE                                                                                                                                                                                                        
   NAME (LAST, FIRST, MIDDLE)                                                     DATE OF BIRTH                  SOCIAL SECURITY NUMBER                            DATE HIRED                   STATE OF HIRE            
                                                                                                                                                                                                                        
   ADDRESS (INCL ZIP)                                                             SEX                            MARITAL STATUS                                    OCCUPATION/JOB TITLE                                  
                                                                                                                                                                                                                         
                                                                                  M     MALE                     nU    UNMARRIEDSINGLE/DIVORCED                    EMPLOYMENT        STATUS                               
                                                                                  F     FEMALE                   M     MARRIED                                                                                          
                                                                                  U     UNKNOWN                  S     SEPARATED                                                                                          
   PHONE                                                                          # OF DEPENDENTS                K     UNKNOWN                                     NCCI CLASS CODE                                       
                                                                                                                                                                                                                        
   RATE                                     DAY             MONTH                       DAYS WORKED/WEEK               FULL PAY FOR DAY OF INJURY?                                     YES           NO                  
   PER:                                     WEEK            OTHER:                                                     DID SALARY CONTINUE?                                            YES           NO                   
   OCCURRENCE/TREATMENT                                                                                                                                                                                                 
   TIME EMPLOYEE          AM       DATE OF INJURY/ILLNESS         TIME OF OCCURRENCE                     AM      LAST WORK DATE                     DATE EMPLOYER                      DATE DISABILITY                   
   BEGAN WORK                                                                                                                                       NOTIFIED                           BEGAN                             
                          PM                                      (  )  CANNOT BE                        PM                                                                                                              
                                                                  DETERMINED                                                                                                                                             
   CONTACT NAME/PHONE NUMBER                                                 TYPE OF INJURY/ILLNESS                                                PART OF BODY AFFECTED                                                
                                                                                                                                                                                                                        
   DID INJURY/ILLNESS/EXPOSURE OCCUR ON EMPLOYER’S                             TYPE OF INJURY/ILLNESS CODE                                         PART OF BODY AFFECTED CODE                                            
   PREMISES?                                                                                                                                                                                                             
                    YES       NO                                                                                                                                                                                         
   DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE                                ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS                                           
   OCCURRED                                                                                 EXPOSURE OCCURRED                                                                                                           
                                                                                                                                                                                                                        
   SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR                       WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE                                                   
   ILLNESS EXPOSURE OCCURRED                                                                OCCURRED                                                                                                                    
                                                                                                                                                                                                                        
   HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED.  DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED                                                                
   THE EMPLOYEE OR MADE THE EMPLOYEE ILL                                                                                                                                                                                 
                                                                                                                                                                    CAUSE OF INJURY CODE                                 
                                                                                                                                                                                                                        
   DATE RETURN(ED)  TO WORK             IF FATAL, GIVE DATE OF DEATH             WERE SAFEGUARDS OR SAFETY       EQUIPMENT   PROVIDED?                                 YES               NO                               
                                                                                 WERE THEY USED?                                                                       YES               NO                               
   PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS)                           HOSPITAL OR OFF SITE TREATMENT (NAME & ADDRESS)                                           INITIAL TREATMENT                                 
                                                                                                                                                                       0     NO MEDICAL TREATMENT                         
                                                                                                                                                                       1     MINOR:    BY EMPLOYER                        
                                                                                                                                                                       2     MINOR CLINIC/HOSP                          
                                                                                                                                                                       3     EMERGENCY          CARE                        
                                                                                                                                                                       4     HOSPITALIZED > 24 HOURS                      
                                                                                                                                                                                                                         
                                                                                                                                                                       5     FUTURELOST TIMEMAJORANTICIPATEDMEDICAL/      
   OTHER                                                                                                                                                                                                                
   WITNESSES (NAME & PHONE #)                                                                                                                                                                                           

   DATE ADMINISTRATOR NOTIFIED              DATE PREPARED         PREPARER’S NAME & TITLE                                                                              PHONE NUMBER                                      
                                                                                                                                                                                                                         
   LWC-WC  IA-1                                                                                                                                                      IAIABC 2002                                         

                                         EMPLOYER’S INSTRUCTIONS 
 
                                        DO NOT ENTER DATA IN SHADED FIELDS 
 
 DATES: 
       Enter all dates in MM/DD/YY format. 
 
 INDUSTRY CODE: 
       This is the code which represents the nature of the employer’s business, which is contained in the Standard 
       Industrial Classification Manual or the North American Industry Classification System, published by the 
       Federal Office of Management and Budget. 
 
 CARRIER: 
       The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf 
       of the employer of the claimant. 
 
 CLAIMS ADMINISTRATOR: 
       Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for 
       administering the claim. 
 
 AGENT NAME & 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. 
 
 OCCUPATION/JOB TITLE:                                                                          
       This is the primary occupation of the claimant at the time of the accident or exposure.  

 EMPLOYMENT STATUS:                                                                             
       Indicate the employee’s work status.  The valid choices are:                             
       Full-Time                On Strike              Unknown                                   Volunteer 
       Part-Time                Disabled               Apprenticeship Full-Time                  Seasonal 
       Not Employed             Retired                Apprenticeship Part-Time                  Piece Worker 
 
 DATE DISABILITY BEGAN: 
       The first day on which the claimant originally lost time from work due to the occupation injury or 
       disease or as otherwise designated by statute. 
 
 CONTACT NAME/PHONE NUMBER: 
       Enter the name of the individual at the employer’s premises to be contacted for additional information. 
 
 TYPE OF INJURY/ILLNESS: 
       Briefly describe the nature of the injury or illness, (eg. Lacerations to the forearm). 
 
 PART OF BODY AFFECTED: 
       Indicate the part of body affected by the injury/illness, (eg. Right forearm, lower back). 
 
 DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED: (eg. 
       Maintenance Department or Client’s office at 452 Monroe St., Washington, DC 26210) 
 
       If the accident or illness exposure did not occur on the employer’s premises, enter address or 
       location. Be specific. 
 
 LWC-WC IA-1                                                                                   IAIABC 2002 
 

                                EMPLOYER’S INSTRUCTIONS – cont’d 
 
ALL EQUIPMENT, MATERIAL OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR 
ILLNESS EXPOSURE OCCURRED: 
      (eg. Acetylene cutting torch, metal plate) 
 
      List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or 
      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 equipment, materials, or chemicals were being used. NOTE: The items listed 
      do not have to be directly involved in the employee’s injury or illness. 
 
SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE 
 OCCURRED: 
      (eg. Cutting metal plate for flooring) 
 
      Describe the specific activity the employee was engaged in when the accident or illness exposure 
      occurred, such as sanding ceiling woodwork in preparation for painting. 
 
WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED: 
      Describe the work process the employee 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 process (eg. 
      walking along a hallway). 
 
HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF 
EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE 
THE EMPLOYEE ILL: 
      (Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against 
      the hot metal.) 
 
      Describe how the injury or illness/abnormal health condition occurred. Include the sequence of events and 
      name any objects or 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 feet to the floor. The 
      worker’s right wrist was broken in the fall. 
 
DATE RETURN(ED) TO WORK: 
      Enter the date following to most recent disability period on which the employee returned to work. 
 
     LWC-WC IA-1