ࡱ>  h>bjbj ljj@(3lRRRR$$$$$|N<}@$a'T:::::::$`= ?;(["}((;.RR?<...(^R8:J=.(:.0.46|7 a60&$)*y77L<0N<7@=*T@7. RRRRMinnesota Department of Labor and Industry First Report of Injury Workers Compensation Division 443 Lafayette Road North See Instructions on Reverse Side St. Paul, Minnesota 55155-4305 Please PRINT or TYPE your responses. (651) 284-5030 Enter dates in MM/DD/YYYY format. F R 0 1 1. EMPLOYEE SOCIAL SECURITY #  FORMTEXT    - FORMTEXT   - FORMTEXT     2. OSHA Case #  FORMTEXT      DO NOT USE THIS SPACE3. DATE OF CLAIMED INJURY  FORMTEXT      4. Time of Injury  FORMTEXT        FORMCHECKBOX  a.m.  FORMCHECKBOX  p.m. 5. Time Employee Began  FORMTEXT        FORMCHECKBOX  a.m. Work on Date of Injury  FORMCHECKBOX  p.m.6. EMPLOYEE Name (last, first, middle)  FORMTEXT      ,  FORMTEXT        FORMTEXT      7. Gender  FORMCHECKBOX  M  FORMCHECKBOX  F8. Marital Status  FORMCHECKBOX  Married  FORMCHECKBOX  Unmarried9. Home Address  FORMTEXT      10. Home Phone # ( FORMTEXT    )  FORMTEXT      - FORMTEXT      11. Date of Birth  FORMTEXT      City  FORMTEXT      State  FORMTEXT MNZIP Code  FORMTEXT      12. Occupation  FORMTEXT      13. Regular Department  FORMTEXT      14. Date Hired  FORMTEXT      15. Average Weekly Wage $  FORMTEXT      16. Rate per Hour $  FORMTEXT      17. Hours per Day  FORMTEXT      18. Days per Week  FORMTEXT      19. Employment  FORMCHECKBOX  Full Time  FORMCHECKBOX  Part Time Status  FORMCHECKBOX  Seasonal  FORMCHECKBOX  Volunteer20. Weekly Value of: $  FORMTEXT      Meals $  FORMTEXT      Lodging $  FORMTEXT      2nd Income $  FORMTEXT      21. Apprentice  FORMCHECKBOX  Yes  FORMCHECKBOX  No22. Tell us how the injury occurred and what the employee was doing before the incident (give details). Examples: Worker was driving lift truck with a pallet of boxes when the truck tipped, pinning workers left leg under drive shaft. Worker developed soreness in left wrist over time from daily computer key entry.  FORMTEXT      23. 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.  FORMTEXT      24. What tools, equipment, machines, objects, or substances were involved? Examples: chlorine, hand sprayer, pallet lift truck, computer keyboard.  FORMTEXT      25. Did injury occur on employer s premises?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If no, indicate name and address of place of occurrence  FORMTEXT      26. Date of First Day of Any Lost Time  FORMTEXT      27. Employer Paid for Lost Time on Day of Injury (DOI)  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  No lost time on DOI28 Date Employer Notified of Injury  FORMTEXT      29. Date Employer Notified of Lost Time  FORMTEXT      30. Return to Work Date  FORMTEXT      31. Date of Death  FORMTEXT      32. TREATING PHYSICIAN (Name, Address and Phone)  FORMTEXT      33. HOSPITAL/CLINIC (Name and Address  if any)  FORMTEXT      34. Emergency Room Visit  FORMCHECKBOX  Yes  FORMCHECKBOX  No35. Overnight In-Patient  FORMCHECKBOX  Yes  FORMCHECKBOX  No 36. EMPLOYER Legal Name  FORMTEXT      37. EMPLOYER DBA Name (if different)  FORMTEXT      38. Mailing Address  FORMTEXT      39. Employer FEIN  FORMTEXT      40. Unemployment ID  FORMTEXT      City  FORMTEXT      State  FORMTEXT MNZIP Code  FORMTEXT      41. Employer s Contact Name and Phone #  FORMTEXT      42. Physical Address (if different)  FORMTEXT      43. Witness (Name and Phone)  FORMTEXT      City  FORMTEXT      State  FORMTEXT MNZIP Code  FORMTEXT      44. NAICS Code  FORMTEXT      45. Date Form Completed  FORMTEXT      46. INSURER Name WESTERN NATIONAL INSURANCE COMPANY51. CLAIMS ADMIN COMPANY (CA) Name (check one)  FORMCHECKBOX  Insurer WESTERN NATIONAL INSURANCE COMPANY  FORMCHECKBOX  TPA47. Insured Legal Name  FORMTEXT      52. CA Address P.O. Box 146348. Policy # or Self-Insured Certificate #  FORMTEXT      City MINNEAPOLISState MNZIP Code 5544049. Insurer FEIN 41043082550. Date Insurer Received Notice  FORMTEXT      53. CA FEIN 41043082554. Claim #  FORMTEXT      MN FR01 (02/06) Copies to: Insurer, Employer, Employee, and Workers Compensation Division (if no insurer) GENERAL INSTRUCTIONS TO THE EMPLOYER Filing this form is not an admission of liability. You must report a claim to your insurer whenever anyone believes that a work-related injury or illness that requires medical care or lost time from work has occurred. If the claimed injury wholly or partially incapacitates the employee for more than three calendar days, the claim must be made on this form and reported to your insurer within ten days. Your insurer may require you to file it sooner. Failure to file within the ten days may result in penalties. Self-insured employers have 14 days to file this form with the Department of Labor and Industry (Department). It is important to file this form quickly to allow your insurer time to investigate the claim. Your insurer will forward a copy of this form to the Department, if necessary. If the claim involves death or serious injury (including injuries that later result in death), you must notify the Department and your insurer within 48 hours of the occurrence. The claim can be reported initially to the Department by telephone (651-284-5041), fax (651-284-5731), or personal notice. The initial notice must be followed by the filing of this form within seven days of the occurrence. Employers are required to complete this form. Each piece of information is needed to determine liability and entitlement to benefits. Failure to complete the form may result in delayed processing and possible penalties. You must file this form with your insurer, and give a copy to the employee and the employees local union office. You are required to provide the employee with a copy of the Employee Information Sheet, which is available on the Departments web site at  HYPERLINK http://www.doli.state.mn.us www.doli.state.mn.us. Employees are not responsible for completing this form. SEND REPORT TO INSURER IMMEDIATELY DO NOT WAIT FOR DOCTORS REPORT SPECIFIC INSTRUCTIONS FOR COMPLETING THIS FORM ( Item 2: OSHA Case #. Fill in the case number from the OSHA 300 log. This form contains all items required by the OSHA form 301. ( Items 15-20: Fill in all the wage information. If the employee does not work a regularly scheduled work week, attach a 26 week wage statement so your insurer can calculate the appropriate average weekly wage. ( Items 22-24: Be as specific as possible in describing: the events causing the injury; the nature of the injury (cut, sprain, burn, etc.), and the part(s) of body injured (back, arm, etc.); and the tools, equipment, machines, objects or substances involved. Item 26: Fill in the first day the employee lost any time from work (including time lost for medical treatment), even if you paid the employee for the lost time. Item 27: Check the appropriate box to indicate if there was lost time on the date of injury and whether you paid for that lost time. ( Item 28: Fill in the date you first became aware of the injury or illness. ( Item 29: Fill in the date you became aware that the lost time indicated in Item 26 was related to the claimed injury. Item 30: Leave the box blank if the employee has not returned to work by the time you file this form. If the employee has returned to work, fill in the date and notify your insurer if the employee misses time due to this injury after that date. ( Item 39: Fill in your Federal Employment ID number (FEIN). For information on this number, see  HYPERLINK http://www.firstgov.gov www.firstgov.gov and click on Employer ID Number under Business. ( Items 40 and 44: Fill in your Unemployment ID number and North American Industry Classification System (NAICS) code which are both assigned by the Minnesota Unemployment Insurance Program (651-296-6141). Items 46-54: Your insurer or claims administrator will complete this information. INSTRUCTIONS TO THE INSURER/CLAIMS ADMINISTRATOR/SELF-INSURED EMPLOYER The following data elements must be completed on this form prior to filing with the Department of Labor and Industry: employees name and social security number; date of injury; and the names of the employer and insurer. If any of this information is missing, the First Report will be rejected and returned to you (per Minn. Stat. 176.275). Providing the name of the third party administrator does not meet the statutory requirement to provide the name of the insurer. NOTE: If the claim does not involve lost time beyond the waiting period or potential PPD, the form does NOT need to be filed with the Department. Item 46: Fill in the name of the insurance company. If the employer is self-insured, indicate the name of the licensed or public self-insured company or group. Item 47-48: Fill in the legal name of the employer who purchased the policy from the insurer (named in Item 46) and the policy number. If the employer is licensed to self-insure, fill in the certificate number. Item 49: Fill in the insurers Federal Employment ID number (FEIN) number. Item 51: Fill in the name and address of the company administering the claim (either the insurer or third party administrator). Be sure to mark either the insurer or TPA box. Item 53-54: Fill in the claims administrators FEIN and claim number. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (652) 297-4198. 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