First Report of Injury
1. EMPLOYEE SOCIAL SECURITY #
4. DATE OF CLAIMED INJURY
Tell us how the injury/illness occurred, what the employee was doing before the incident (give details), and what the injury/illness was. Examples: “Worker was driving
lift truck with a pallet of boxes when the truck tipped, pinning worker’s left leg under drive shaft.” “Worker developed soreness in left wrist over time from daily computer key entry.”
What was the injury or illness (include the part(s) of body)? Examples:
chemical burn left hand, broken left leg, carpal tunnel syndrome in left wrist.
What tools, equipment, machines, objects, or substances were involved?
Examples: chlorine, hand sprayer, pallet lift truck, computer keyboard.
CLAIMS ADMIN COMPANY (CA)
GENERAL INSTRUCTIONS TO THE EMPLOYER
Employers, not employees,
Filing this form is not an admission of liability
Your insurer will report the injury