Date of This Report

Reported on behalf of: N e w Y o r k S t a t e I n s u r a n c e F u n ______d ______Employer Interview-Long Version

Date of this report:

Claimant: NYSIF Case#: -Unit - D/A:

Agency Name: NWI Investigative Group, Inc. Investigation Date:

Person who conducted investigation: Title: Investigator

Agency Investigation No.: NYSIF Investigation No.:

Phone Field By Appointment Preliminary report #: Final report

Employer Information:

Employer

Owner(s) / Partner(s) Name(s)

Address visited

Telephone number

Informant's name Title

Was NYSIF the Workers’ Compensation carrier on the date of accident?

If no, provide details Re: Cancellation & date

Correct carrier information as follows Check with requester if necessary to continue interview

If yes, continue interview

Nature of business

OSHA number UI registration number

Disability carrier Disability address Claimant Information:

Date of Birth Age (If less than 25-WEC62? , working papers?)

Address Phone #

Gender Race

Height Weight

Eye color Hair color

Distinguishing marks Social Security #

Is the claimant an owner/officer or related to an owner or officer?

If yes, what is the relationship?

Date of Hire Job title

Union/negotiating unit/local Department

Name of the claimant's immediate supervisor

Description of claimant's regular work duties

Claimant's regular work week Claimant's scheduled work hours

Does claimant work full or part time?

Is claimant a regular, seasonal, casual, loaned, subcontracted, independent contractor, volunteer or temporary employee?

If yes, explain

Is claimant a field worker?

If yes, explain

2 Accident Information:

Date of Accident Time of Accident

Did the accident occur on employer's premises? If yes, at which location?

If no, address where accident occurred

Description of how accident occurred

Nature of injury and body part

Object that injured claimant

Witnesses

Is a third party involved? If yes, explain

Notice:

Who gave notice?

Date and Time given? Oral or Written?

Notice given to whom? Title? Phone number?

Lost Time/Wages:

Is the claimant currently employed by policyholder?

If no, why? Separation date

Claimant's last day worked Last day paid

Was claimant paid in full for the day? If no, explain

List periods of lost time (C-11?)

Has claimant RTW? (C-11?) Date claimant RTW (C-11?)

3 Regular wages? (C-11?) If no, reduced wkly wage (C-11?)

Is/was claimant paid by employer for lost time? (C-107?)

Gross earnings for prior 52 weeks, including bonus, comm., room/board (C-240?)

Medical Treatment:

Was first aid rendered to claimant at the scene?

By whom, and to what extent?

Was claimant hospitalized? How was claimant transported?

Name of hospital

Address Phone number

Claimant was initially treated by

Primary doctor

Address Phone number

Priors:

Is employer aware of prior conditions, illnesses, injuries or accidents claimant has suffered? (Hypertension, Diabetes, Patent Defects, Eyeglasses, Contact Lenses Etc.)

If yes, explain

Did any of these involve compensation claims?

If yes, explain

Was the State Insurance Fund the carrier for any of these accidents?

If yes, explain

4 Alternate Duty:

Is light duty available? Was it offered to claimant?

Did claimant refuse or accept?

Describe the light duty

Other Benefits:

Has claimant applied for Unemployment, Disability or SSI benefits?

If yes, are they receiving benefits? Amount Start Date

Retirement Information:

Has claimant filed for retirement or otherwise indicated intent to retire at a given time/age?

If yes, type: Disability, or Regular?

Effective date

Does claimant have a pension plan?

If yes, at what age is claimant eligible to retire under pension plan?

Is employer aware of claimant seeking employment elsewhere?

Comments: Does employer have any reason to believe the claimant will abuse or take advantage of his/her workers' compensation benefits?

Does employer have any reason to dispute the accident / occurrence?

Important Evidence and Indicators

Follow up Undertaken/ Suggested

5 Any other comments?

List evidence being mailed to Point Person

Approved by: William J. Donnelly Rev 10/13 *