"First Report of Occupational Injury or Disease" - Delaware

First Report of Occupational Injury or Disease is a legal document that was released by the Delaware Department of Labor - a government authority operating within Delaware.

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ALL COPIES OF THIS FIRST REPORT MUST BE TYPED OR PRINTED
Department of Labor
STATE OF DELAWARE
Office of Workers’ Compensation (OWC)
FIRST REPORT
4425 N. Market Street
Wilmington, DE 19802
OF OCCUPATIONAL INJURY OR DISEASE
OWC Case File No.
Telephone 302-761-8200
ALL INFORMATION IS REQUIRED, unless not applicable where “if applicable” is noted.
EMPLOYEE:
1.
MIDDLE
LAST
2. EMPLOYEE SOCIAL SECURITY NO.
FIRST
3. ADDRESS – INCLUDE COUNTY AND ZIP CODE
4.
5. EMPLOYEE PHONE NUMBER
MALE
(INCLUDING AREA CODE)
FEMALE
6. DATE OF BIRTH
7. AGE
8. WAGE
9. WEEKLY HOURS WORKED
/
/
10. OCCUPATION (REGULAR)
11. DEPARTMENT OR DIVISION REGULARLY EMPLOYED
12. HOW LONG EMPLOYED
EMPLOYER:
14. PERSON MAKING OUT THIS REPORT
13.
15. ADDRESS – INCLUDE COUNTY AND ZIP CODE
16. EMPLOYER PHONE # (INCLUDE AREA CODE)
17. MAILING ADDRESS – IF DIFFERENT THAN ABOVE
18. NATURE OF BUSINESS – TYPE OF MFG., TRADE,
CONSTURCTION, SERVICE, ETC.
WORKERS’ COMPENSATION INSURANCE CARRIER
20. WORKERS’ COMP. INS. CARRIER PHONE #, (INCLUDING AREA CODE
19.
21. WORKERS’ COMP. INSURANCE CARRIER ADDRESS
22. POLICY NUMBER / CARRIER CASE NUMBER:
/
23. THIRD PARTY ADMINISTRATOR (TPA), IF APPLICABLE
24. TPA ADDRESS – INCLUDE CITY STATE AND ZIPCODE
DATES:
28. IF EMPLOYEE BACK TO
WORK GIVE DATE
29. AT SAME WAGE?
25. DATE OF REPORT
26. DATE OF INJURY
27. NORMAL STARTING TIME
/
/
/
/
/
/
AM
PM
YES
NO
30. IF FATAL INJURY, GIVE DATE OF DEATH
31. DATE EMPLOYER KNEW OF INJURY
32. DATE DISABILITY BEGAN
33. LAST FULL DAY PAID-DATE
/
/
/
/
/
/
/
/
INJURY OR DISEASE:
34. DESCRIBE THE INJURY/ILLNESS AND PART OF BODY AFFECTED.
35. SPECIFY THE DEPARTMENT WHERE INCIDENT OCCURRED AND THE WORK PROCESS INVOLVED.
OCCURRENCE:
36. LIST THE EQUIPMENT, MATERIALS, AND CHEMICALS EMPLOYEE USED WHEN THE INCIDENT OCCURRED, E.G. ACETYLENE.
37. DESCRIBE THE EMPLOYEE’S ACTIVITY AT THE TIME OF INJURY OR ILLNESS, E.G. LIFTING A PATIENT.
38. DESCRIBE HOW THE INJURY/ILLNESS OCCURRED.
39. NAME OF PHYSICIAN (IF APPLICABLE)
40. PHYSICIAN’S ADDRESS
41. HOSPITAL (IF APPLICABLE)
42. HOSPITAL ADDRESS
DISTRIBUTION OF THIS REPORT (1 original and 3 copies)
1.
ORIGINAL MUST BE SENT IMMEDIATELY TO THE WORKERS’ COMPENSATION INSURANCE CARRIER.
2.
COPY TO THE OFFICE OF WORKERS’ COMPENSATION (use the address at the top left of this form)
3.
EMPLOYER’S COPY – RETAIN AS RECORD
4.
EMPLOYEE’S COPY
ALL COPIES OF THIS FIRST REPORT MUST BE TYPED OR PRINTED
Department of Labor
STATE OF DELAWARE
Office of Workers’ Compensation (OWC)
FIRST REPORT
4425 N. Market Street
Wilmington, DE 19802
OF OCCUPATIONAL INJURY OR DISEASE
OWC Case File No.
Telephone 302-761-8200
ALL INFORMATION IS REQUIRED, unless not applicable where “if applicable” is noted.
EMPLOYEE:
1.
MIDDLE
LAST
2. EMPLOYEE SOCIAL SECURITY NO.
FIRST
3. ADDRESS – INCLUDE COUNTY AND ZIP CODE
4.
5. EMPLOYEE PHONE NUMBER
MALE
(INCLUDING AREA CODE)
FEMALE
6. DATE OF BIRTH
7. AGE
8. WAGE
9. WEEKLY HOURS WORKED
/
/
10. OCCUPATION (REGULAR)
11. DEPARTMENT OR DIVISION REGULARLY EMPLOYED
12. HOW LONG EMPLOYED
EMPLOYER:
14. PERSON MAKING OUT THIS REPORT
13.
15. ADDRESS – INCLUDE COUNTY AND ZIP CODE
16. EMPLOYER PHONE # (INCLUDE AREA CODE)
17. MAILING ADDRESS – IF DIFFERENT THAN ABOVE
18. NATURE OF BUSINESS – TYPE OF MFG., TRADE,
CONSTURCTION, SERVICE, ETC.
WORKERS’ COMPENSATION INSURANCE CARRIER
20. WORKERS’ COMP. INS. CARRIER PHONE #, (INCLUDING AREA CODE
19.
21. WORKERS’ COMP. INSURANCE CARRIER ADDRESS
22. POLICY NUMBER / CARRIER CASE NUMBER:
/
23. THIRD PARTY ADMINISTRATOR (TPA), IF APPLICABLE
24. TPA ADDRESS – INCLUDE CITY STATE AND ZIPCODE
DATES:
28. IF EMPLOYEE BACK TO
WORK GIVE DATE
29. AT SAME WAGE?
25. DATE OF REPORT
26. DATE OF INJURY
27. NORMAL STARTING TIME
/
/
/
/
/
/
AM
PM
YES
NO
30. IF FATAL INJURY, GIVE DATE OF DEATH
31. DATE EMPLOYER KNEW OF INJURY
32. DATE DISABILITY BEGAN
33. LAST FULL DAY PAID-DATE
/
/
/
/
/
/
/
/
INJURY OR DISEASE:
34. DESCRIBE THE INJURY/ILLNESS AND PART OF BODY AFFECTED.
35. SPECIFY THE DEPARTMENT WHERE INCIDENT OCCURRED AND THE WORK PROCESS INVOLVED.
OCCURRENCE:
36. LIST THE EQUIPMENT, MATERIALS, AND CHEMICALS EMPLOYEE USED WHEN THE INCIDENT OCCURRED, E.G. ACETYLENE.
37. DESCRIBE THE EMPLOYEE’S ACTIVITY AT THE TIME OF INJURY OR ILLNESS, E.G. LIFTING A PATIENT.
38. DESCRIBE HOW THE INJURY/ILLNESS OCCURRED.
39. NAME OF PHYSICIAN (IF APPLICABLE)
40. PHYSICIAN’S ADDRESS
41. HOSPITAL (IF APPLICABLE)
42. HOSPITAL ADDRESS
DISTRIBUTION OF THIS REPORT (1 original and 3 copies)
1.
ORIGINAL MUST BE SENT IMMEDIATELY TO THE WORKERS’ COMPENSATION INSURANCE CARRIER.
2.
COPY TO THE OFFICE OF WORKERS’ COMPENSATION (use the address at the top left of this form)
3.
EMPLOYER’S COPY – RETAIN AS RECORD
4.
EMPLOYEE’S COPY
WORKERS’ COMPENSATION
IMPORTANT THINGS TO DO IN CASE OF INJURY
THE EMPLOYER SHOULD:
1. Provide all necessary medical, surgical and hospital treatment from the date of accident.
2. Every employer shall keep a record of all injuries received by employees and make a report within 10
days thereof in writing to the Office of Workers’ Compensation
3. Ascertain the average weekly wages of the employee and provide compensation in accordance with the
provisions of the law, for disability beyond the third day after the accident. All agreements as to
compensation must be submitted to the Office of Workers’ Compensation for approval.
THE EMPLOYEE SHOULD:
1. Immediately notify the employer in writing of accidental injury or occupational disease and request medical
services. Failure to give notice or to accept medical services may deprive the employee of the right to
compensation.
2. Give promptly to the employer, directly or through a supervisor, notice of any claim for compensation for
the period of disability beyond the third day after the accident. In case of fatal injuries, notice must be given
by one or more dependents of the deceased or by a person on their behalf.
3. In case of failure to reach an agreement with the employer in regard to compensation under the law, file
application with the Industrial Accident Board for a hearing on the matters at issue within two years of the
date of accidental injury or one year of knowledge of the diagnosis of an occupational disease or an ionizing
radiation injury. All forms can be obtained from the Office of Workers’ Compensation.
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