OSHA Log Case # First Report Adjuster Date Stamp
of Injury or Occupational Disease
Montana Department of Labor and Industry
PO Box 8011, Helena, MT 59604-8011
Worker
Last Name First Name M.I. Date of Birth Social Security Number
Mailing Address City State Postal Code
Phone Number Education Less Than High School Gender Marital Status Number of Dependents
GED or High School Diploma Male Female Married Separated
Beyond High School Unknown Widowed, Divorced, Single, Unmarried
Unknown
Wages
Date Hired Gross earnings for four pay periods preceding the injury
Date/Amount / Date/Amount / Date/Amount / Date/Amount /
Employment Status Number of Days worked per week Wage Wage Period
Full-Time Part-Time Piece Worker Seasonal Hour Week Month Day Bi-Weekly
Volunteer Other
In addition to gross earnings cited above worker received Estimated value if any Time Employee began work
Room & Board Overtime Bonus Commissions Other:
Worked next scheduled shift Off work more than 4 work days Date Last Worked Date of Return to Work Full wages paid for date of injury Salary Continued
Yes No Yes No Not Sure Yes No Yes No
Accident Description
Job Title Description of Accident
Cause of Injury Cause Code Part of Body Part Code Nature of Injury Nature Code Date of Injury Time of Injury
Date Disability Began Date of Death Names of Witnesses
1) 2) 3)
Accident on Employer’s Premises Accident Address or Location
Yes No City State Postal code
Date Employer Notified Accident Reported to Safety Equipment Provided Safety Equipment Used
Yes No Yes No
Medical
Attending Physician’s Name Address State Postal Code Phone Number
Hospital Name Address State Postal Code Phone Number
Type of initial medical treatment received No Treatment Emergency Room/Urgent Care Treatment on-site by Employer or Medical Staff Clinic/Dr. Office
Hospital > 24 hours
Signature
“This is my claim for workers’ compensation benefits due to the on-the-job injury, occupational disease, or death of the above named worker. I understand that signing this claim for compensation
authorizes the release to the workers’ compensation insurer (and its agents) and to the Montana Uninsured Employers’ Fund of: Social Security records; rehabilitation records; and all health care
information (medical records, pursuant to HIPAA, Public Law 104-191, 42 USC section 1301, et. seq., and section 39-71-604, MCA), that are directly relevant to the claimed injury, disease, or
death. I also understand that if I obtain or exert unauthorized control over workers’ compensation benefits to which I am not entitled, I may be prosecuted for theft.”
Signature of Injured Worker or Beneficiary Date:
Employer
Employer Name Doing Business as Federal Employer Identification Number (Tax I.D)
Mailing Address City State Postal Code Phone Number
Location of operation, if different from mailing address Nature of Business Self-Insured Yes No
SIC/NAICS Code
Employer is a Sole Proprietorship Partnership Injured worker is a Sole Proprietorship Partnership Corporation Limited Liability Company
Corporation Limited Liability Company A member of the employer’s (sole proprietor) family living in the employer’s household.
Do you have any reason to question this accident? Yes No Was worker injured while in your employ
If yes, please explain fully. Use separate sheet if you need additional space Yes No
Prepared By Official Title Phone Number Date
Payroll Classification Code under which you
report Employee’s wages
Authorized Employer’s Signature ________________________________________ Date__________________________
Insurer
Claim Administrator Claim Number Date Reported to Claim Administrator: The above information is correct with the following exceptions
(Attach extra sheets if box at right is checked)
Claim Administrator Name Claim Administrator Address Claim Administrator FEIN
Insurer Name Insurer FEIN
Policy Number Policy Effective Date Policy Expiration Date
ERD – 991 (Rev. 05/2016 DE)