Cannot be determined
INDIANA WORKER’S COMPENSATION
FIRST REPORT OF EMPLOYEE INJURY, ILLNESS
State Form 34401 (R10 / 1-02)
FOR WORKER’S COMPENSATION BOARD USE ONLY
Jurisdiction
Jurisdiction claim number Process date
Please return completed form electronically by an approved EDI process.
PLEASE TYPE or PRINT IN INK
NOTE: Your Social Security number is being requested by this state agency in order to pursue its statutory responsibilities. Disclosure is voluntary and you will
not be penalized for refusal.
EMPLOYEE INFORMATION
Social Security number
Date of birth
Sex
Male Female Unknown
Name (last, first, middle)
Marital status
Address (number and street, city, state, ZIP code)
Telephone number (include area Number of dependents
Unmarried
Married
Separated
Unknown
Occupation / Job title
NCCI class code
Employee status
Date hired State of hire
Hrs / Day Days / Wk Avg Wg / Wk
Paid Day of Injury
Salary Continued
Wage
Per
$
Hour
Year
Day
Other
Week
Month
EMPLOYER INFORMATION
Name of employer
Address of employer (number and street, city, state, ZIP code)
Employer ID#
Location number
Telephone number
Carrier / Administrator claim number
SIC code
Insured report number
Employer’s location address (if different)
Report purpose code
Actual location of accident / exposure (if not on employer’s premises)
CARRIER / CLAIMS ADMINISTRATOR INFORMATION
Name of claims administrator
Address of claims administrator (number and street, city, state, ZIP code)
Telephone number
Name of agent
Carrier federal ID number
Code number
Check if appropriate
Policy / Self-insured number
Policy period
Insurance Carrier
Third Party Admin.
Self Insurance
From To
OCCURRENCE / TREATMENT INFORMATION
Date of Inj./ Exp.
Last work date
RTW date
Department or location where accident / exposure occurred
Specific activity engaged in during accident / exposure
How injury / exposure occurred. Describe the sequence of events and include any relevant objects or substances.
Name of physician / health care provider
Name of witness
Date prepared
Time of occurrence
Date employer notified
Type of injury / exposure
Type code
Time workday began
Date of death
Date disability began Part of body
Telephone number Date administrator notified
Telephone number
Name of preparer
Title
Cause of injury code
Part code
Injury / Exposure occurred
on employer’s premises?
Yes
No
Name of contact
Telephone number
All equipment, materials, or chemicals involved in accident
Work process employee engaged in during accident / exposure
INITIAL TREATMENT
No Medical Treatment
Minor: By Employer
Minor: Clinic / Hospital
Emergency Care
Hospitalized > 24 Hours
Future Major Medical / Lost
Time Anticipated
AM PM
An employer’s failure to report an occupational injury or illness may result in a $50 fine (IC 22-3-4-13).
OSHA log number
Hospital or offsite treatment (name and address)
Reset Form
INSTRUCTIONS
General Instructions:
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.
Definitions:
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
used (e.g. Acetylene cutting torch, metal plate, etc.).
AVG WG/WK: Claimant’s average weekly wage, calculated by totaling the latest 52 weeks of wages (including overtime, tips, etc.) and
dividing by 52.
CLAIMS ADMINISTRATOR: Enter the name of the carrier, third-party administrator, state fund, or self-insured responsible for administering
the claim.
CONTACT NAME / TELEPHONE NUMBER: Enter the name of the individual at the employer’s premises to be contacted for additional
information (i.e. Supervisor, HR Person, Nurse, etc.)
DATE DISABILITY BEGAN: The first day on which the claimant originally lost time from work due to the occupational injury or disease
or as otherwised deigned by statute.
DEPARTMENT OR LOCATION WHERE ACCIDENT OR EXPOSURE OCCURRED: If the accident or exposure did not occur on the
employer’s premises, enter address or location. Be specific (e.g. Maintenance, Client’s Office, Cafeteria, etc.).
EMPLOYEE STATUS: Indicate the employee’s work status from the following choices: Full-time, Part-time, Apprentice Full-time, Apprentice
Part-time, Volunteer, Seasonal Worker, Piece Worker, On-Strike, Disabled, Retired, Not Employed or Unknown (you may also abbreviate
the above as: (FT, PT, AFT, APT, VO, SW, PW, OS, DI, RE, NE, or UK).
HOW INJURY / ILLNESS OCCURRED: Describe the sequence of events leading to the injury or exposure (e.g. Worker stepped back
to inspect work and slipped on some scrap metal. As worker fell, he brushed against the hot metal; Worker stepped to the edge of the
scaffolding, lost balance and fell six feet to the concrete floor. The worker’s right wrist was broken in the fall).
NCCI CLASS CODE: A four-digit code classifying the occupation of the claimant.
OCCUPATION / JOB TITLE: Enter the primary occupation of the claimant at the time of the accident or exposure.
PART OF BODY AFFECTED: Indicate the part of body affected by the injury / illness (e.g. Right forearm, Low Back, etc.)
REPORT PURPOSE CODE: 00 = Original First Report of Injury; 02 = Updated or Amended First Report.
RTW DATE (Return to Work Date): Enter the date following the most recent disability period on which the employee returned to work.
SIC CODE: This is the code which represents the nature of the employer’s business which is contained in the Standard Industrial
Classification Manual published by the Federal Office of Management and Budget.
SPECIFIC ACTIVITY EMPLOYEE ENGAGED IN DURING ACCIDENT / EXPOSURE: Describe the specific activity the employee was
engaged in during the accident or exposure (e.g. Cutting metal plate for flooring, sanding ceiling woodwork in preparation for painting).
TYPE OF INJURY / ILLNESS: Briefly describe the nature of the injury or illness (e.g. Contusion, Laceration, Fracture, etc.)
WORK PROCESS THE EMPLOYEE WAS ENGAGED IN DURING ACCIDENT / EXPOSURE: Enter “NA” if employee was not engaged
in a work process, such as if walking down the hallway (e.g. Building maintenance).
Indiana Worker's Compensation Board 12/28/17
WORKER'S COMPENSATION NOTICE
Your employer is required to provide for payment of benefits under the Worker's Compensation
Act of the State of Indiana.
Any employee who is injured while at work should report the injury immediately to their
supervisor, employer, or designated representative.
The worker's compensation insurance carrier or the administrator for
________________________________________ is: ______________________________________
(name of company) (name of insurance carrier or administrator)
__________________________________________________________________________
(name of carrier/administrator)
_________________________________________________________________________
(mailing address)
_________________________________________________________________________
(city, state, zip)
_________________________________________________________________
(telephone number)
________________________________________________________________________
(contact person)
For more information about rights or procedures under the Indiana Worker's Compensation
system, call or write:
Worker's Compensation Board of Indiana
Ombudsman Division
402 W. Washington St., Rm W196
Indianapolis, IN 46204
(317) 232-3808
1-800-824-2667
NOTICIA DE COMPENSACION PARA TRABAJADORES
A su empleador le es requerido proveer pagos de beneficios bajo el Acta de Compensación para
Trabajadores del Estado de Indiana.
Cualquier empleado que sea lesionado mientras esté trabajando debe reportar el accidente
laboral inmediatamente a su supervisor, empleador o representante designado.
La compaňía de seguro de compensación del trabajador o el administrador de la compaňía
______________________________________ es:
(nombre de la compaňía)
___________________________________________________________________________________
(nombre de la compaňía de seguro/administrador)
___________________________________________________________________________________
(dirección)
____________________________________________________________________________
(ciudad, estado, código postal)
__________________________________________________________________________________
(número de teléfono)
___________________________________________________________________________________
(persona de contacto)
Para más información acerca de sus derechos o los procedimientos bajo el sistema de
compensación para trabajadores de Indiana, llame o escriba a:
Worker's Compensation Board of Indiana
Ombudsman Division
402 W. Washington St., Rm W196
Indianapolis, IN 46204
(317) 232-3808
1-800-824-2667