3. Nature of Business: 4. Employer’s Name: 5. Address: City: State: 1. Name: Last Zip: First 6. Telephone: MI 7. Telephone: State: Zip: 3. Date of Birth: M F - 9. Marital Status: Full-Time Part-Time Retired – Date Retired: Volunteer Time: a.m. 1. Date of Injury or Last Exposure: - 8. Social Security Number: 4. Sex: 5. Injured Employee is: (check all that apply) Owner / Partner Officer - 6. Date Hired: 2. Address: City: - 10. Employee’s Occupation / Job Title: p.
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How to use or fill out the WV BrickStreet BI-3 online
Filling out the WV BrickStreet BI-3 form is an essential step in reporting an employee's injury efficiently and accurately. This guide will walk you through the process of completing this form online, ensuring you provide all necessary information.
Follow the steps to complete the BI-3 form accurately.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- In the 'Employer Information' section, enter the BrickStreet insurance policy number, FEIN or SSN, nature of the business, and the employer's name and address, including the city, state, and zip code.
- Move to the 'Employee Information' section. Input the employee's name, telephone number, date of birth, social security number, sex, marital status, and employment status (full-time, part-time, retired, or volunteer).
- Fill in the 'Injury Information' section by providing the date of the injury or last exposure, the date the employer was notified, the supervisor to whom the injury was reported, and indicate if the injury was fatal along with the date of death.
- Describe the injury by specifying if it occurred on the employer's property, detailing what the employee was doing at the time, how the injury occurred, the nature of the injury or disease, and the body parts injured.
- In the 'Wage and Lost Time Information' section, report the last day worked, the number of workdays lost, if light duty is available, wages being paid during disability, and the daily rate of pay on the date of injury.
- Complete the certification statement at the bottom of the form by printing your name, title, and signing with the date.
- After completing the form, review all entries for accuracy. Save changes, download, print, or share the form as required.
Complete the WV BrickStreet BI-3 form online today to ensure timely reporting of workplace injuries.
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Understanding your income levels is crucial for tax benefits. If your income is $200,000 or less, you may qualify for certain credits and deductions, including those related to dependents. This information will assist you in making informed decisions about your claims. For guidance and resources, check out the WV BrickStreet BI-3.
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How does workers' compensation work in WV?
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What should be done immediately after an injury in the workplace?
Immediately after an injury in the workplace, your first move should be to ensure the safety of the injured person. Call for help and provide first aid if trained to do so. Following that, notify your supervisor and document the incident comprehensively, which is essential for processes involving WV BrickStreet BI-3.
What is the first step after an injury?
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What is the first thing that must be done when a worker is injured?
The first action to take when a worker is injured is to assess the situation for safety. Ensure that the injured party is out of danger before you offer assistance. Next, document the scene and gather information about the incident, as this will be vital for claims under WV BrickStreet BI-3.
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