First Report of Injury or Illness

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IA-1 WORKERS COMPENSATION Ð FIRST REPORT OF INJURY OR ILLNESS
Employer (Name & Address incl. zip)
 Carrier/Administrator Claim Number
 Report Purpose Code
Jurisdiction
 
Jurisdiction Claim Number
Insured Report Number
Employer's Location Address
(if different)
 Location No.
SIC Code
 Employer FEIN
 Phone Number
Carrier (Name, Address & Phone Number) Policy Period Claims Admin (Name, Address & Phone Number)

To
Check if self insured
Carrier FEIN
  Policy or Self-Insured Num
 
Administrator FEIN
Agent Name & Code Number
Legal Name (Last, First, Middle)
 Date of Birth
 Social Security No. Date Hired
 State of Hire
Address (Incl. Zip)
 Sex Marital Status Occupation/Job Title
Male Unmarried/
Single/Div.
Female Married Employment Status
Unknown Separated
Phone
 Num Dependents
 Unknown NCCI Class Code
Wage Rate

$		 Day Month # Days Worked / WK
 Full Pay for Date of Injury? Yes No
Week Other
 # Hrs Worked /  Day
 Did Salary Continue? Yes No
Time Employee
Began Work
 AM Date of Injury or Illness
 Time Occurred
 AM Last Work
Date
 Date Employer Notified
 Date Disability Began
PM PM
Employer Contact Name/Phone Number
 Type of Illness/Injury
 Part of Body Affected
Did Injury/Illness Exposure Occur on Employer's Premises? Yes
Type of Illness/Injury Code
Part of Body Affected Code
No
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 Returned to Work
 If Fatal,
Date of Death
Were Safeguards or Safety Equipment Provided? Yes No
Were they used? Yes No
Physician/Health Care Provider
(Name & Address)
 Hospital
(Name & Address)
 Initial Treatment
0 No Medical Treatment
1 Minor: By Employer
2 Minor Clinic/Hosp
3 Emergency Care
4 Hospitalized > 24 hr.
Witness to Accident (Name & Phone Number)
 5 Future Major Medical/Lost
Time Anticipated
DateAdministratorNotified
 Date Prepared
 Preparer's Name & Title
 Preparer's Phone Number
IA-1 (2/95) SEE NEXT PAGE FOR IMPORTANT STATE INFORMATION/SIGNATURE

 

REPRINTED WITH PERMISSION OF IAIABC

Applicable in Alaska
A person who willfully makes a false or misleading statement or representation for the purpose of obtaining or denying a benefit or payment is guilty of theft by deception.
Applicable in Arkansas
Any person or entity who willfully and knowingly makes any material false statement or representation for the purpose of obtaining any benefit or payment, or for the purpose of defeating or wrongfully decreasing any claim for benefit or payment or obtaining or avoiding worker's compensation coverage or avoiding payment of the proper insurance premium (or who aids and abets for either said purpose), under this chapter shall be guilty of a Class D. felony.
Applicable in California
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony.
Applicable in Connecticut
This form must be completed in its entirety. Any person who intentionally misrepresents or intentionally fails to disclose any material fact related to a claimed injury may be guilty of a felony.
Applicable in Delaware and Oklahoma
Any person who, knowingly and with intent to injure, defraud, or deceive any Insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. The lack of such a statement shall not constitute a defense against prosecution under this section. *Delaware Statutes Regulation: Del #C Section 913(B)
Applicable in Florida
Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company or self-insured program, files any statement of claim containing any false or misleading information is guilty of a felony of the third degree.
Applicable in Idaho
Any person who Knowingly and with the intent to injure, Defraud, or Deceive any Insurance Company, Files a Statement of Claim Containing any False, Incomplete or Misleading information is Guilty of a Felony.
Applicable in Indiana
A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.
Applicable in Kentucky and New York
Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. In New York, such person shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Applicable in Michigan
Any person who knowingly and with intent to injure or defraud any insurer submits a claim containing any false, incomplete, or misleading information shall, upon conviction, be subject to imprisonment for up to one year for a misdemeanor conviction or up to ten years for a felony conviction and payment of a fine of up to $5,000.00.
Applicable in Minnesota
A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
Applicable in Nevada
Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete or misleading information concerning a material fact is guilty of a felony.
Applicable in New Hampshire
Any person who, with purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.
Applicable in New Jersey
Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
Applicable in Ohio
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Applicable in Pennsylvania
Any person who knowingly and with intent to injure or defraud any insurer files a claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years or payment of a fine of up to $50,000.
Applicable in Utah
Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison.
EMPLOYEE SIGNATURE:
IA-1 (2-95)		  


Risk Management Services Company P.O. Box 22989 Louisville KY 40252
(502)326-5900 (800)372-5402 (502)326-5909-fax