NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION
EMPLOYERS' FIRST REPORT OF INJURY OR ILLNESS
2410 CENTRE AVE. SE PO BOX 27198
ALBUQUERQUE, NM 87125-7198
OFFICIAL USE ONLY
PLEASE PRINTEMPLOYER IN BLACK( NAME INK& ADDRESS OR TYPE.INCL ZIP ) CARRIER / ADMINISTRATOR CLAIM # OSHA LOG NUMBER REPORT PURPOSE CODE
G JURISDICTION JURISDICTION CLAIM NUMBER
E
N
INSURED REPORT NUMBER
E
R EMPLOYER'S LOCATION ADDRESS ( IF DIFFERENT ) LOCATION #
A PHONE NUMBER
EMPLOYER FEIN INDUSTRY CODE
L
CARRIER ( NAME, ADDRESS & PHONE NO ) POLICY PERIOD CLAIMS ADMINISTRATOR ( NAME, ADDRESS & PHONE NO )
C
A TO
C
L
R A
I
R M CHECK SELF IF APPROPRIATEINSURANCE
S
I A CARRIER FEIN POLICY / SELF-INSURED NUMBER ADMINISTRATOR FEIN
D
E M
I
N
R AGENT NAME & CODE NUMBER
E NAME ( LAST, FIRST, MIDDLE ) DATE OF BIRTH SOCIAL SECURITY NUMBER DATE HIRED STATE OF HIRE
M
ADDRESS ( INCL ZIP ) GENDER MARITAL STATUS OCCUPATION/JOB TITLE OR (SOC)
P MALE UNMARRIED CODE
L SINGLE/DIVORCED
O FEMALE MARRIED EMPLOYMENT STATUS
Y UNKNOWN SEPARATED
E PHONE NUMBER # OF DEPENDENTS NCCI CLASS CODE
UNKNOWN
E
A
W RATE PER: DAY MONTH # DAYS WORKED/WEEK FULL PAY FOR DAY OF INJURY? YES YES NO
G WEEK OTHER: DID SALARY CONTINUE? NO
E
AM
TIME EMPLOYEE DATE OF INJURY/ILLNESS TIME OF AM LAST WORK DATE EMPLOYER DATE DISABILITY BEGAN
BEGAN WORK OCCURRENC DATE NOTIFIED
O PM E PM
C CONTACT NAME / PHONE NUMBER TYPE OF INJURY/ILLNESS PART OF BODY AFFECTED
C TYPE OF INJURY / ILLNESS CODE PART OF BODY AFFECTED CODE
DID INJURY/ILLNESS EXPOSURE YES OCCUR ON EMPLOYER'S PREMISES?NO
U DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN
OCCURRED ACCIDENT OR ILLNESS EXPOSURE OCCURRED
R
SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS
R ILLNESS EXPOSURE OCCURRED EXPOSURE OCCURRED
E
HOW INJURY OR ILLNESS / ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT
N DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL.
CAUSE OF INJURY CODE
C
YES
E DATE RETURNED TO WORK IF FATAL, GIVE DATE OF DEATH WEREWERE SAFEGUARDSTHEY USED? OR SAFETY EQUIPMENT PROVIDED? NO
YES NO
T PHYSICIAN / HEALTH CARE PROVIDER ( NAME & ADDRESS ) HOSPITAL ( NAME & ADDRESS ) INITIAL TREATMENT
R NO MEDICAL TREATMENT
E
A MINOR: BY EMPLOYER
T
M MINOR CLINIC/HOSPITAL
E
NT EMERGENCY CARE
O WITNESSES ( NAME & PHONE # ) HOSPITALIZED > 24 HRS
T FUTURE MAJOR MEDICAL/
H LOST TIME ANTICIPATED
E DATE ADMINISTRATOR NOTIFIED DATE PREPARED PREPARER'S NAME & TITLE
R
NM WCA FORM E1.2 EQUIVALENT TO OSHA'S FORM 301 FORM IA-1 (7/02) IAIABC 2002
Completion of this form is not an admission that the claim is compensable under the Workers’ Compensation Act.