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WORKERS COMPENSATION
First Report of Injury

  • Please provide as much information about the claim as possible
  • Required fields are marked by the * symbol.
  • If you do not have the information for a required field, please enter "unknown".
Employee Information
* First Name * Last Name

* Occupation/Job Title

* Street Address

Suite/Building

City

State

Zip

* County

Telephone

Telephone 2

* Sex
Male Female

* Marital Status
Married Single Widowed Divorced Unknown

* Number of Dependents
Unknown Number, if known:

* Employment Status
Full-time Part-time Seasonal Volunteer Other:

* Date of Birth (MM/DD/YYYY)

Social Security Number


Employer Information
* Employer Name * SIC #:

Employer FEIN

Employer/Policy Self-Insured Number

* Street Address

Building/Suite

* City

* State

* Zip

* County

* Telephone
Telephone 2

Fax

* Full Pay For Day of Injury
Yes No Unknown:

Time Employee Began Work

Time of Occurrence
AM PM AM PM

* Date of Injury (MM/DD/YYYY)

* Date of Hire (MM/DD/YYYY)

Policy Period From (MM/DD/YYYY)

Policy Period To (MM/DD/YYYY)

Last Day Worked (MM/DD/YYYY)

Date Disability Began (MM/DD/YYYY)

Date Employer Notified (MM/DD/YYYY)

Date Returned to Work (MM/DD/YYYY)

Contact First Name

Last Name

Telephone

Telephone 2

Fax


Accident/Injury Information
Type of Injury or Illness Parts of Body Affected

Cause of Injury

* Did injury or illness occur on employer's premises?
Yes No Unknown

* Were safeguards or safety equipment provided?
Yes No Unknown

If out of state, specify state of injury

All equipment, materials or chemicals employee was using when accident or illness occurred:

* How injury or illness / abnormal health condition occurred. Describe the sequence of events and include any objects or substances directly responsible

* Did accident/illness result in fatality?
Unknown No Yes (enter date):

* Initial Treatment
No Medical Treatment Minor By Employee Clinic/Hospital
Panel Physician Employee Physician Emergency Care
Hospitalized More Than 24 Hours Unknown


Physician/Health Care Provider

First Name

Last Name

City

State

Zip

Telephone

Other Phone #

Fax #

Hospital Name

Street Address

City

State

Zip


Assignment Instructions
Scope of Assignment Detail / Instructions:


Witness Information
#1 - First Name Last Name

Telephone

#2 - First Name

Last Name

Telephone


Preparer/Administrator Information

Person Completing This Form

* Company Name

* First Name

* Last Name

* Title

Phone

Other Phone

Fax

* E-Mail Address

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Insurance Carrier or Third Party Administrator (if Self-insured):
CLAIMS SERVICE CORPORATION OF AMERICA
901 Moorefield Park Drive, Suite 110
Richmond, VA 23236
United States
Service Contact: Roy Hinton
Phone: (804) 320-6000 (24 HR)
Fax: (804) 320-6060

Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act and may be subject to criminal and civil penalties through Pennsylvania Act 155.

©2007 Claim Service Corporation of America. All rights reserved.