1. Please enter information into all of the areas of the First Report form, except the boxes at the top right corner of the form which
is for office use only.
2. Enter all dates in MM/DD/YY format.
3. Please return completed form electronically by an approved EDI process.
4. For answers to questions, please call (317) 232-3808.
AGENT NAME AND CODE NUMBER: Enter the name of your insurance agent and his / her code number if known. This information
can be found on your insurance policy.
ALL EQUIPMENT, MATERIALS OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR EXPOSURE OCCURRED: List
anything the employee was using, applying, handling or operating when the injury or exposure occurred. If the injury involves a fall, indicate
any surfaces and / or objects the claimant fell on and where they fell from. Enter “NA” if no equipment, materials or chemicals were being
e.g. Acetylene cutting torch, metal plate, etc.).
AVG WG/WK: Claimant’s average we