Get Employers First Report Of Occupational Injury Nh Form

This guide provides users with clear instructions on how to complete the Employers First Report Of Occupational Injury Nh Form online. By following the steps outlined below, users will be able to submit the necessary information accurately and efficiently.

Follow the steps to fill out the Employers First Report Of Occupational Injury Nh Form online effectively.

1. Click ‘Get Form’ button to access the Employers First Report Of Occupational Injury Nh Form and open it in your preferred document editor.
2. Enter the name of the injured person in the designated fields — First, Middle Initial, and Last names.
3. Provide the date of birth (DOB) for the injured person.
4. Indicate the age of the injured individual.
5. Input the Social Security Number (SS No.) of the injured person.
6. Select the gender of the injured person by checking either Male or Female.
7. Enter the complete address of the injured individual, including street number, street name, city/town, state, and ZIP code.
8. Provide the telephone number of the injured person.
9. State if there is a New Hampshire Youth Employment Certificate on file.
10. Document the occupation of the injured person at the time of the injury.
11. Enter the number of days worked per week by the injured individual.
12. List the average weekly earnings of the injured person.
13. Specify the date when the disability began.
14. Indicate if the injured person was paid in full for the day of the injury.
15. Confirm whether the job in which the injury occurred was the regular occupation of the individual; if not, state the regular occupation.
16. State whether the injured individual was hired in New Hampshire.
17. Document the date when the supervisor/employer was first notified of the injury.
18. List the date and time of the injury.
19. Provide the name of the person who was notified about the injury.
20. Enter the location or job site where the accident occurred.
21. Provide a detailed description of how the accident occurred and what the employee was doing at the time of injury.
22. List the parts of the body that were injured.
23. Provide the names of any witnesses to the accident.
24. Indicate whether the injured individual has returned to work.
25. If applicable, state the date the injured person returned to work.
26. Specify the occupation or job the injured person returned to.
27. Confirm whether the individual returned to full duty or alternative/light duty.
28. Describe the equipment that caused the injury.
29. State if safeguards were in place at the time of the accident.
30. Document the initial treatment the individual received, checking all that apply.
31. Provide the name of the treating physician.
32. Enter the employer's Federal ID.
33. Specify the business SIC code.
34. If the person injured was a leased or temporary worker, provide the client's business name.
35. Enter the business address of the client’s business.
36. List the insurance company or indicate if self-insured.
37. Indicate if there is a Managed Care Program and provide the provider name.
38. Confirm if there is a written safety program in force.
39. Describe the nature of the business in New Hampshire.
40. If the report was sent by an insurance agency, specify the agency name.
41. Print or type the name and official title of the person completing the report.
42. Include the employee's signature if possible.
43. Document the date of the report.
44. Finally, review all entries for accuracy, save changes, and take the opportunity to download, print, or share the completed form as needed.

Complete your Employers First Report Of Occupational Injury Nh Form online today to ensure prompt filing.