Get Employer (name & Address Incl Zip) Carrieradministrator Claim Number Report Purpose Code

Filling out the employer claim form is an important step in reporting workplace injuries or illnesses. This guide will walk you through the process of accurately completing the EMPLOYER (NAME & ADDRESS INCL ZIP) CARRIERADMINISTRATOR CLAIM NUMBER REPORT PURPOSE CODE online, ensuring you provide all necessary information effectively.

Follow the steps to successfully complete the online form.

1. Press the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by entering the employer's name and complete address, including ZIP code, in the designated field labeled 'EMPLOYER (NAME & ADDRESS INCL ZIP)'. This is crucial for identifying the reporting entity.
3. Input the carrier or administrator's details and the claim number in their respective sections. This helps in tracking the claim accurately.
4. Specify the jurisdiction related to the claim. This usually refers to the state or region where the injury or illness occurred.
5. Enter the report purpose code. This code specifies the reason for the report, such as a first report of injury.
6. If applicable, fill in the jurisdiction claim number and the insured report number to provide additional context to the claim.
7. Complete the employer's location address if it differs from the main address provided previously.
8. Enter the Standard Industrial Classification (SIC) code which categorizes the type of business.
9. Fill in the employer Federal Employer Identification Number (FEIN) and the carrier’s details, including name, address, and phone number.
10. Next, enter the policy period for the insurance coverage in question.
11. Provide the claims administrator's name, address, and telephone number.
12. Indicate if the employer is self-insured by checking the appropriate box, and include the necessary FEIN and self-insured number if applicable.
13. Complete the agent’s name and code number if relevant.
14. Proceed to the employee wage section, entering the full name, date of birth, and social security number of the affected employee.
15. Fill out the employment details including the date hired, address, sex, marital status, and occupation/job title.
16. Specify the employment status and the number of dependents the employee has.
17. Detail the date and time of injury or illness, along with whether the injury occurred on the employer's premises.
18. Describe the nature of the injury or illness, providing necessary specifics, including the part of the body affected.
19. Document any eyewitnesses and their contact information.
20. Once all information is accurate, save your changes and proceed to download or print the form to share it as needed.

Complete and file your documents online to ensure timely processing of claims.