Fillable Printable S.C. Workers' Compensation Commission First Report of Injury or Illness - Washington

S.C. Workers' Compensation Commission First Report of Injury or Illness - Washington

S.C. WORKERS’ COMPENSATION COMMISSION – 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)

LOCATION #

INDUSTRY CODE

EMPLOYER FEIN

PHONE #

CARRIER/CLAIMS ADMINISTRATOR

CARRIER (NAME, ADDRESS, & PHONE #)

POLICY PERIOD

CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO)

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

STATE OF HIRE

ADDRESS (INCL ZIP)

SEX

Male

Female

Unknown

MARITAL STATUS

Unmarried/Single/Divorced

Married

Separated

Unknow

OCCUPATION/JOB TITLE

EMPLOYMENT STATUS

NCCI CLASS CODE

PHONE

# OF DEPENDENTS

RATE

PER:

DAY

MONTH

DAYS

WORKED/WEEK

FULL PAY FOR DAY OF INJURY?

YES

WEEK

OTHER:

DID SALARY CONTINUE?

YES

OCCURRENCE/TREATMENT

TIME

EMPLOYEE

BEGAN WORK

DATE OF INJURY/ILLNESS

TIME OF OCCURRENCE

LAST WORK DATE

DATE EMPLOYER NOTIFIED

DATE DISABILITY BEGAN

( ) CANNOT BE DETERMINED

CONTACT NAME/PHONE NUMBER

TYPE OF INJURY/ILLNESS

PART OF BODY AFFECTED

DID INJURY/ILLNESS/EXPOSURE

OCCUR ON EMPLOYER’S PREMISES?

TYPE OF INJURY/ILLNESS CODE

PART OF BODY AFFECTED CODE

YES

DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR

ILLNESS EXPOSURE OCCURRED

WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT

DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL

CAUSE OF INJURY CODE

DATE RETURN(ED) TO WORK

IF FATAL, GIVE DATE OF DEATH

WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED?

WERE THEY USED?

YES

PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS)

HOSPITAL OR OFF SITE TREATMENT (NAME & ADDRESS)

INITIAL TREATMENT

0 No Medical Treatment

1 MINOR: BY EMPLOYER

2 MINOR CLINIC/HOSP

3 EMERGENCY CARE

4 HOSPITALIZED > 24 HOURS

5 FUTURE MAJOR MEDICAL/ LOST TIME ANTICIPATED

OTHER

WITNESSES (NAME & PHONE #)

DATE ADMINISTRATOR NOTIFIED

DATE PREPARED

PREPARER’S NAME & TITLE

PHONE NUMBER

WCC FORM 12A

REV. DATE 04/06

SEE INSTRUCTIONS FOR IMPORTANT INFORMATION

REPRINTED WITH PERMISSION OF IAIABC

South Carolina Workers’ Compensation Commission

1333 Main Street, Suite 500

P.O. BOX 1715

Columbia, SC 29202-1715

803-737-5722

EMPLOYER’S INSTRUCTIONS

DO NOT ENTER DATA IN SHADED FIELDS

DATES:

Enter all dates in MM/DD/YYYY format.

INDUSTRY CODE:

This is the code which represents the nature of the employer’s business, which is contained in the Standard

Industrial Classification Manual or the North American Industry Classification System, published by the Federal

Office of Management and Budget.

CARRIER:

The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of

the employer of the claimant.

CLAIMS ADMINISTRATOR:

Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administering

the claim.

AGENT NAME & 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.

OCCUPATION/JOB TITLE:

This is the primary occupation of the claimant at the time of the accident or exposure.

EMPLOYMENT STATUS:

Indicate the employee’s work status. The valid choices are:

Full-Time On Strike Unknown Volunteer

Part-Time Disabled Apprenticeship Full-Time Seasonal

Not Employed Retired Apprenticeship Part-Time Piece Worker

DATE DISABILITY BEGAN:

The first day on which the claimant originally lost time from work due to the occupation injury or disease or as

otherwise designated by statute.

CONTACT NAME/PHONE NUMBER:

Enter the name of the individual at the employer’s premises to be contacted for additional information.

TYPE OF INJURY/ILLNESS:

Briefly describe the nature of the injury or illness, (e.g. Lacerations to the forearm).

PART OF BODY AFFECTED:

Indicate the part of body affected by the injury/illness, (e.g. Right forearm, lower back).

DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED:

(e.g. Maintenance Department or Client’s office at 452 Monroe St., Washington, DC 26210)

If the accident or illness exposure did not occur on the employer’s premises, enter address or location.

Be specific.

WCC FORM 12A REV. DATE 04/06

South Carolina Workers’ Compensation Commission

1333 Main Street, Suite 500

P.O. BOX 1715

Columbia, SC 29202-1715

803-737-5722

EMPLOYER’S INSTRUCTIONS – cont’d

ALL EQUIPMENT, MATERIAL OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS

EXPOSURE OCCURRED:

(e.g. Acetylene cutting torch, metal plate)

List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or operating

when the injury or illness occurred. Be specific, for example: decorator’s scaffolding, electric sander, paintbrush,

and paint.

Enter “NA” for not applicable if no equipment, materials, or chemicals were being used. NOTE: The items listed

do not have to be directly involved in the employee’s injury or illness.

SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE

OCCURRED:

(e.g. Cutting metal plate for flooring)

Describe the specific activity the employee was engaged in when the accident or illness exposure occurred,

such as sanding ceiling woodwork in preparation for painting.

WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED:

Describe the work process the employee was engaged in when the accident or illness exposure occurred, such

as building maintenance. Enter “NA” for not applicable if employee was not engaged in a work process (e.g.

walking along a hallway).

HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF

EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE

THE EMPLOYEE ILL:

(Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against

the hot metal.)

Describe how the injury or illness/abnormal health condition occurred. Include the sequence of events and

name any objects or substance that directly injured the employee or made the employee ill. For example:

Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The

worker’s right wrist was broken in the fall.

DATE RETURN(ED) TO WORK:

Enter the date following to most recent disability period on which the employee returned to work.

WCC FORM 12A REV. DATE 04/06