Get First Report Of Injury Form - Pkt Enterprises

Filling out the First Report Of Injury Form is a critical step in reporting a workplace injury. This guide provides clear instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to access the document and open it within your preferred editor for completion.
2. Begin by filling in the employee's social security number in the designated field. Remember to leave the 'DO NOT USE THIS SPACE' area blank.
3. Enter the OSHA case number, if applicable, in the corresponding field.
4. Input the date of the claimed injury in MM/DD/YYYY format.
5. Specify the time of the injury, selecting AM or PM as relevant.
6. Record the time the employee began work on the day of the injury, noting AM or PM.
7. Fill in the employee's full name (last, first, middle) in the provided space.
8. Indicate the gender of the employee by selecting 'M' for male or 'F' for female.
9. Mark the marital status of the employee as married or unmarried accordingly.
10. Enter the employee’s home phone number.
11. Fill in the employee's home address, including city, state, and zip code.
12. Record the employee's date of birth.
13. Provide the employee's occupation.
14. Indicate the regular department where the employee works.
15. Enter the date the employee was hired.
16. Fill in the average weekly wage of the employee.
17. Specify the rate per hour.
18. Indicate the number of hours the employee works per day.
19. Fill in the number of days the employee works per week.
20. Select the appropriate employment status: full-time, part-time, seasonal, or volunteer.
21. Mark whether the employee is an apprentice.
22. Describe how the injury occurred, providing specific details about what the employee was doing at the time.
23. Specify the nature of the injury and identify the body part(s) involved.
24. List any tools, equipment, or substances involved in the incident.
25. Indicate whether the injury occurred on the employer’s premises.
26. Provide the date of the first day of lost time due to the injury.
27. Indicate if the employer paid for lost time on the date of injury.
28. Fill in the date the employer was notified of the injury.
29. Provide the date the employer was notified of lost time.
30. Note the return-to-work date, leaving the field blank if the employee has not returned.
31. If applicable, enter the date of death.
32. Provide the name, address, and phone number of the treating physician.
33. Supply the name and address of any hospitals or clinics visited.
34. Indicate whether the employee visited the emergency room.
35. Specify if the employee was an overnight inpatient.
36. Record the employer's legal name.
37. Enter the employer's doing business as (DBA) name, if different.
38. Fill in the mailing address of the employer.
39. Provide the employer’s federal employment identification number (FEIN).
40. Enter the employer's unemployment ID number.
41. List the employer's contact name and phone number.
42. Input the witness name and phone number, if applicable.
43. Include the NAICS code.
44. State the date the form was completed.
45. Fill in the insurer's name.
46. Indicate the name of the claims administration company.
47. Complete the section for the insured legal name.
48. Fill in the policy number or self-insured certificate number.
49. Provide the insurer's FEIN.
50. State the date the insurer received notice.
51. Complete the claims administrator's FEIN and claim number.
52. After completing the form, save your changes, and consider downloading or printing for your records.

Complete your documents online to ensure a swift and accurate process.