Louisiana First Report of Injury Or IllnessLouisiana First Report of Injury Or IllnessLouisiana First Report of Injury Or Illness
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WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS
EMPLOYER (NAME & ADDRESS INCL ZIP)

CARRIER/ADMINISTRATOR CLAIM NUMBER

OSHA LOG NUMBER

REPORT PURPOSE CODE

JURISDICTION

JURISDICTION CLAIM NUMBER

INSURED REPORT NUMBER
EMPLOYER’S LOCATION ADDRESS (IF DIFFERENT)
INDUSTRY CODE

LOCATION #

EMPLOYER FEIN

PHONE #

CARRIER/CLAIMS ADMINISTRATOR
CARRIER (NAME, ADDRESS, & PHONE #)

POLICY PERIOD

CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO)
TO

CHECK IF APPROPRIATE

SELF INSURANCE

CARRIER FEIN

POLICY/SELF-INSURED NUMBER

ADMINISTRATOR FEIN

AGENT NAME & CODE NUMBER

EMPLOYEE/WAGE
NAME (LAST, FIRST, MIDDLE)

DATE OF BIRTH

SOCIAL SECURITY NUMBER

DATE HIRED

ADDRESS (INCL ZIP)

SEX

MARITAL STATUS

OCCUPATION/JOB TITLE

M

MALE

F
FEMALE
U UNKNOWN
# OF DEPENDENTS

PHONE
RATE
PER:

DAY
WEEK

MONTH

DAYS WORKED/WEEK

OTHER:

STATE OF HIRE

U

UNMARRIED
SINGLE/DIVORCED

EMPLOYMENT STATUS

M
S
K

MARRIED
SEPARATED
UNKNOWN

NCCI CLASS CODE