First Report of Injury Notice

ADM OCIP Workers’ Compensation First Report of Injury Notice Please complete the entire form and provide copy to the OCIP Insurance Representative REPORT TO www.zurichna.com or 1-877-928-4531 WITHIN 8 HOURS Master Policy WC 3481902 EMPLOYEE INFORMATION Employee’s Name: Employee’s Address: Employee’s Phone: Site Code/ADM Plant: Male Female Marital Status: No. Of Dependents: Date Of Birth: Age: Social Security No.: Occupation: Supervisor: Date Hired: Average Weekly Wage: Or Hourly Wage: Hours Worked? Paid For Date Of Injury (Y/N): No. Hours Per Week? First Full Day Out: Date Last Worked: Disability Began: Date Returned To Work: Estimated Return To Work: Lost Time: Yes No EMPLOYER INFORMATION Employer Name: Employer Address: Zurich WC Policy #: Employer Business Type: Employer Contact: Employer Sic #: Employer Federal Id Number: Il Unemployment Compensation No: Total # Of Employees At The Location Where Illness/Injury Occurred: INCIDENT INFORMATION Date Of Injury: Time: Am Pm Day Of The Week: Was The Incident On ADM Premises?: Yes No If Yes, Describe Exact Location: Date Claim Was Reported To Employer: Person Notifed At Employer’s: Give Full Description Of Incident (What Exactly Was Employee Doing When Injured?): List Witness Names And Telephone Numbers:

ADM OCIP WC 1st Report of Injury 2016 ADM OCIP Workers’ Compensation First Report of Injury Notice Please complete the entire form and provide copy to the OCIP Insurance Representative REPORT TO www.zurichna.com or 1-877-928-4531 WITHIN 8 HOURS Master Policy WC 3481902

INJURY INFORMATION Type Of Injury-Check One: Abrasion Amputation Contusion Crush Fracture Laceration Puncture Strain Sprain Other: Body Part Injured-Check One: : Head Eye Arm Neck Shoulder Back Torso Hand Leg Ankle Foot Other: Right Or Left-Check One: Right Left Cause Of Accident-Check One: Burn Caught In Or Between Cut, Puncture, Scraped Fall Or Slip Strain/Sprain Struck Against Struck By Miscellaneous Multiple Injuries Other: Was Employee Wearing Personal Protective Equipment? Yes No If Yes, What Type? Was Employee Given Industrial Commission Handbook? Yes No Did Incident Result In Occupational Injury Or Disease? Yes No MEDICAL INFORMATION Treatment-Check One: No Med. Treatment Minor On Site First Aid Clinic Physician Emergency/Released Hospitalized Other: Hospital/Clinic - Name, Address: Diagnosis, If Known: Was This Injury Related To A Prior Injury Or Pre- If Yes, Provide Details Existing Condition? ADDITIONAL INFORMATION Illinois Question: What Unsafe Act By A Person Caused Or Contributed To The Injury Or Illness?