S.C. Workers’ Compensation Commission – First Report of Injury or Illness 1 EMPLOYEE/WAGE2 OCCURRENCE/TREATMENT3 OTHER Employer NameEmployer Address Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Industry CodeThis 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.Employer FEINCarrier/Administration Claim NumberOSHA Log NumberReport Purpose CodeJurisdictionJurisdiction Claim NumberInsured Report NumberEmployer's Location Address (If different) Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Location No.Phone No.Carrier Name First Last The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer of the claimant.Carrier Address Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Carrier Phone No.Carrier FEINPolicy Period From To Check if appropriate Self Insurance Policy/Self-Insured NumberClaims Administrator Name First Last Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administering the claim.Claims Administrator Address Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Claims Administrator Phone No.Administrator FEINAgent Name First Last Enter the name of your insurance agent if known. This information can be found on your insurance policy.Agent Code NumberEnter your insurance agent code number if known. This information can be found on your insurance policy.Employee Name First Middle Last Address Street Address Address Line 2 City State *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone No.Date of Birth Date Format: MM slash DD slash YYYY SexMaleFemaleUnknownNo. of DependentsSocial Security NumberMarital StatusUnmarried / Single / DivorcedMarriedSeparatedUnknownDate Hired Date Format: MM slash DD slash YYYY State of HireOccupation/Job TitleThis is the primary occupation of the claimant at the time of the accident or exposure.Employment StatusFull-TimePart-TimeNot EmployedOn StrikeDisabledRetiredUnknownApprenticeship Full-TimeApprenticeship Part-TimeVolunteerSeasonalPiece WorkerNCCI Class CodeRatePerDayWeekMonthOtherDays Worked/WeekFull pay for day of injuryYesNoDid Salary Continue?YesNo Time Employee Began Work : HH MM AM PM Date of Injury/Illness * Date Format: MM slash DD slash YYYY Time of Occurence : HH MM AM PM Cannot Be Determined Cannot Be Determined Last Work Date Date Format: MM slash DD slash YYYY Date Employer Notified Date Format: MM slash DD slash YYYY Date Disability Began Date Format: MM slash DD slash YYYY 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 NameEnter the name of the individual at the employer’s premises to be contacted for additional information.Contact Phone No.Did injury/illness/exposure occur on employer's premises?YesNoType of Injury/IllnessBriefly describe the nature of the injury or illness, (e.g. Lacerations to the forearm)Type of Injury/Illness CodePart of Body AffectedIndicate the part of body affected by the injury/illness, (e.g. Right forearm, lower back).Part of Body Affected CodeDepartment 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.All equipment, materials, 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 occurredDescribe 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. Cause of Injury CodeDate return(ed) to work Date Format: MM slash DD slash YYYY Enter the date following to most recent disability period on which the employee returned to work.If fatal, give date of death Date Format: MM slash DD slash YYYY Were safeguards or safety equipment provided?YesNoWere they used?YesNoPhysician/Health Care NamePhysician/Health Care Address Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Hospital or Off Site Treatment NameHospital or Off Site Treatment Address Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Initial Treatment 0 - No medical treatment 1 - Minor: By Employer 2 - Minor Clinic/Hospital 3 - Emergency Care 4 - Hospitalized > 24 hours 5 - Future major medical / Lost time anticipated WITNESSES (NAME & PHONE #) Date Administrator notified Date Format: MM slash DD slash YYYY Date Prepared Date Format: MM slash DD slash YYYY Preparer's Name First Last Preparer's TitlePhone