First Report Of Injury Worksheet

Incident/Claim No: ______First Report of Injury Worksheet 1. Investigate the incident/injury 2. Fill out this form completely. 3. Upon completion of the form, immediately call 1-800-835-6651 or fax to 678-686-6388. The GMA Claims Reporting Center. 4. Claims can be reported 24 hours a day, 7 days a week, 365 days a year via fax. The Claims Line is open from 8:00 AM to 4:30 PM M-F. Messages left after hours will be returned the next business day. 5. Keep a copy of this worksheet on file for your records.

______Employer Name Employer Phone Number

______Employer Address City, State and Zip Code

______Department Employee’s Occupation

______Employee Name Date of Hire

______Employee Address City, State and Zip Code

Social Security # ______/_____/______Home Phone: ______Age: ______; Date of Birth: ______/______/______, Sex M______, F______Hours worked per day: ______Per week: ______# of days per week: ______Wage at time of injury: $______per hour; $______per day; $______per week; $______per month ______Date of Injury Place of Accident or Exposure (address) County of Injury

Did accident occur: On Employers’ Premises: Y______N______Time of Injury: ______AM/PM Date Employer was Notified: ____/_____/____ Did employee work the next day: Y______N______First day employee failed to work a full day: ____/_____/_____ Did employee receive full pay for the date of injury? Y_____ N_____ If employee returned to work, give date: ______/______/______Returned to work at what wages: $______per week

How did the Injury or Exposure occur? (Please be specific, use additional sheet if necessary)

What was the source of the injury? (Part of body, machine or incident that caused the injury/exposure)

If Fatal, Give Date of Death: ______/______/______

Name and address of Physician or Facility where treated: ______

Report prepared by: ______Title: ______

Phone number: ______Date: ______

EMPLOYER’S FAILURE TO SUBMIT THIS REPORT TO INSURER IMMEDIATELY MAY RESULT IN PENALTY.

Willfully making a false statement for the purpose of obtaining or denying benefits is a crime subject to penalties of up to $10,000 per violation (O.C.G.A.§34-9-18 and §34-9-19). REV. DATE 7/2003