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 
 
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                         U UNMARRIED                  EMPLOYMENT STATUS 
                                                                                                                       SINGLE/DIVORCED 
                                                                            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
                                                                                                                                                                  NO 
PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS)                           HOSPITALWERE THEYOR OFFUSED?SITE TREATMENT (NAME & ADDRESS)                  YES                           
                                                                                                                                                       INITIAL  TREATMENT            
                                                                                                                                                           NO MEDICAL TREATMENT 
                                                                                                                                                         0 
                                                                                                                                                           MINOR: BY EMPLOYER 
                                                                                                                                                         1 
                                                                                                                                                           MINOR CLINIC/HOSP 
                                                                                                                                                         2 EMERGENCY CARE 
                                                                                                                                                         3 
                                                                                                                                                           HOSPITALIZED > 24 HOURS 
                                                                                                                                                         4 FUTURE MAJOR MEDICAL/ 
                                                                                                                                                       5   LOST TIME ANTICIPATED 
OTHER 
WITNESSES (NAME & PHONE #) 
 
DATE ADMINISTRATOR NOTIFIED                    DATE PREPARED     PREPARER’S NAME & TITLE                                                               PHONE NUMBER 

FORM IA-1(r 1-1-02)                                     SEE BACK FOR IMPORTANT INFORMATION                                                         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. 
  
FORM IA-1(r 1-1-02)           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.  
 
 FORM IA-1(r 1-1-02)           IAIABC 2002                                