Get Libc 344 Rev 1 01

Filling out the Libc 344 Rev 1 01 form is an essential step in reporting an occupational injury or disease. This guide will assist you in understanding each section and field of the form, ensuring that you provide accurate and complete information.

Follow the steps to successfully complete the Libc 344 Rev 1 01 form online.

1. Click ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by entering the employee's social security number in the designated field. This is critical for accurate identification.
3. Fill in the date of injury by selecting the month, day, and year when the incident occurred.
4. Enter the employee's first and last names in the corresponding fields.
5. Provide the complete street address, city, state, and ZIP code of the employee.
6. Specify the county and the employee's phone number.
7. Indicate the number of dependents and the employee's date of birth using the format of month, day, and year.
8. Select the employee's gender and marital status from the available options.
9. Include the occupation or job title of the employee to clarify their role.
10. If known, fill in the NCCI class code and specify the employment status (full-time, part-time, seasonal, volunteer, or other).
11. Input the employer's information including name, street address, city, state, ZIP code, SIC code, FEIN, and phone number.
12. Specify the county and NAICS code for the employer.
13. Indicate if full pay was provided for the day of injury and specify the time the employee began work along with the time of occurrence.
14. Enter the last day worked, the date disability began, date employer was notified, and date the employee returned to work.
15. Fill in the date of hire as well as the contact person's first and last name and phone number.
16. Complete the injury details by entering type of injury code, part of body affected code, and cause of injury code if known.
17. Answer whether the injury or illness occurred on the employer's premises and acknowledge if safety equipment was used.
18. Describe how the injury or illness occurred and mention any objects or substances involved.
19. Provide details of the initial treatment and, if applicable, the date of death for fatal incidents.
20. Include the physician's name and the hospital name along with their addresses.
21. Fill out the policy period and any insurance or self-insured numbers required.
22. Indicate the witness's name and contact number.
23. Complete the name, title, and phone number of the person completing the form, as well as insurance carrier information.
24. Finally, ensure all information is complete and accurate, then save your changes, download, print, or share the form as needed.

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