Fillable Adjuster Date Stamp First Report Wages Worker of (National American Insurance Company)

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Adjuster Date Stamp First Report Wages Worker of (National American Insurance Company)

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First Report
Adjuster Date Stamp
of Injury or Occupational Disease
Montana Department of Labor and Industry
PO Box 8011 Helena, MT 59604-8011
Worker
LAST NAME
FIRST NAME
M.I.
DATE OF BIRTH
SOCIAL SECURITY NUMBER
MAILING ADDRESS
CITY
STATE
P
HONE
N
UMBER
E
DUCATION
L
ESS
T
HAN
H
IGH
S
CHOOL
GED OR HIGH SCHOOL DIPLOMA
BEYOND HIGH SCHOOL
G
ENDER
MALE FEMALE
UNKNOWN
M
ARITAL
S
TATUS
MARRIED SEPARATED
WIDOWED, DIVORCED, SINGLE, UNMARRIED
U
NKNOWN
N
UMBER OF
D
EPENDANTS
Wages
D
ATE
H
IRED
G
ROSS EARNINGS FOR FOUR PAY PERIODS PRECEDING THE INJURY
DATE/AMOUNT / DATE/AMOUNT / DATE/AMOUNT / DATE/AMOUNT /
EMPLOYMENT STATUS
FULL TIME PART TIME SEASONAL PIECE WORKER
VOLUNTEER OTHER
NUMBER OF DAYS WORKED PER WEEK
WAGE
WAGE PERIOD
HOUR WEEK MONTH DAY BI-WEE
KLY
IN ADDITION TO GROSS EARNINGS CITED ABOVE WORKER RECEIVED ESTIMATED VALUE IF ANY
ROOM & BOARD OVERTIME BONUS COMMISSIONS OTHER
TIME EMPLOYEE BEGAN WORK
WORKED NEXT SCHEDULED SHIFT
YES NO
OFF WORK MORE THAN 4 WORK DAYS
YES NO NOT SURE
DATE LAST WORKED
DATE OF RETURN TO WORK
FULL WAGES PAID FOR
DATE OF INJURY
YES NO
SALARY CONTINUED
YES NO
Accident Description
JOB TITLE
DESCRIPTION OF ACCIDENT
CAUSE OF INJURY
CAUSE CODE
PART OF BODY
PART CODE
NATURE OF INJURY
NATURE CODE
DATE OF INJURY
TIME OF INJURY
DATE DISABILITY BEGAN
DATE OF DEATH
NAMES OF WITNESSES
1) 2) 3)
ACCIDENT ON EMPLOYER’S PREMISES
YES NO
ACCIDENT ADDRESS OR LOCATION
CITY STATE POSTAL CODE
D
ATE EMPLOYER NOTIFIED
A
CCIDENT
R
EPORTED TO
S
AFETY EQUIPMENT PROVIDED
YES NO
S
AFETY
E
QUIPMENT USED
YES NO
Medical
A
TTENDING
P
HYSICIAN
’
S
N
AME
A
DDRESS
S
TATE
P
OSTAL
C
ODE
P
HONE NUMBER
HOSPITAL NAME
ADDRESS
STATE
POSTAL CODE
PHONE NUMBER
T
YPE OF INITIAL MEDICAL TREATMENT RECEIVED
N
O
T
REATMENT
E
MERGENCY ROOM
/U
RGENT
C
ARE
T
REATMENT ON
-
SITE BY EMPLOYER OR MEDICAL
S
TAFF
C
LINIC
/D
R
.
O
FFICE
HOSPITAL>24 HOURS
Signature
“This is my claim for workers’ compensation benefits due to the on-the-job injury, occupational disease, or death of the above named worker. I understand that signing this claim for
compensation authorizes the release to the workers’ compensation insurer (and its agents) and to the Montana Uninsured Employers’ Fund of: Social Security records; rehabilitation records; and
all health care information (medical records, pursuant to HIPAA, Public Law 104-191, 42 USC section 1301, et. seq., and section 39-71-604, MCA), that are directly relevant to the claimed
injury, disease, or death. I also understand that if I obtain or exert unauthorized control over workers’ compensation benefits to which I am not entitled, I may be prosecuted for theft.”
Signature of Injured Worker or Beneficiary Date
Employer
E
MPLOYER NAME
D
OING
B
USINESS AS
F
EDERAL
E
MPLOYER
I
DENTIFICATION
N
UMBER
(T
AX
ID)
MAILING ADDRESS
CITY
STATE
POSTAL CODE
PHONE NUMBER
L
OCATION OF OPERATION
,
IF DIFFERENT FROM MAILING ADDRESS
N
ATURE OF
B
USINESS
NAICS CODE
S
ELF
-I
NSURED
?
Y
ES
N
O
EMPLOYER IS A SOLE PROPRIETORSHIP PARTNERSHIP
CORPORATION LIMITED LIABILITY COMPANY
INJURED WORKER IS A SOLE PROPRIETORSHIP PARTNERSHIP CORPORATION LIMITED LIABILITY COMPANY
A MEMBER OF THE EMPLOYER’S (SOLE PROPRIETOR OR PARTNER) FAMILY LIVING IN THE EMPLOYER’S HOUSEHOLD
DO YOU HAVE ANY REASON TO QUESTION THIS ACCIDENT? YES NO
IF YES, PLEASE EXPLAIN FULLY. USE SEPARATE SHEET IF YOU NEED ADDITIONAL SPACE
WAS WORKER INJURED WHILE IN YOUR EMPLOY
YES NO
Prepared By
Official Title
Phone Number
Date
P
AYROLL
C
LASSIFICATION
C
ODE UNDER WHICH YOU
REPORT
EMPLOYEE’S WAGES
A
UTHORIZED EMPLOYER’S SIGNATURE_______________________________________________ DATE__________________________
Insurer
CLAIM ADMINISTRATOR CLAIM NUMBER
DATE REPORTED TO CLAIM ADMINISTRATOR
THE ABOVE INFORMATION IS CORRECT WITH THE FOLLOWING EXCEPTIONS
(A
TTACH EXTRA SHEETS IF BOX AT RIGHT IS CHECKED)
C
LAIM
A
DMINISTRATOR
’
S
N
AME
C
LAIM
A
DMINISTRATOR
A
DDRESS
C
LAIM
A
DMINISTRATOR
FEIN
INSURER NAME
INSURER FEIN
POLICY NUMBER
POLICY EFFECTIVE DATE
POLICY EXPIRATION DATE
ERD – 991 (Rev. 08/2014 DE) DLI-ERD-WCC041
OSHA Log Case #
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Adjuster Date Stamp First Report Wages Worker of (National American Insurance Company)

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Completed 29 July 2021

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