<p> Gallagher Bassett Services, GALLAGHER BASSET SERVICES, INC. Inc.</p><p>THE FIRST SIX FIELDS ARE REQUIRED TO PROCESS A FIRST REPORT OF INJURY EMPLOYER: 1. Contact Name: 2. Claimant Social Security Number: 3. Date of Loss: Brenda Dahl 4. Client Number: 5. Branch Number: 6. Benefit State: 002519 (Community First Program) 180 (Roseville) CA Contact Phone Number: Provide FAX number for confirmation to be sent: Location ID: (if unknown leave blank) 415-457-3200 x145 415-456-6374 </p><p>EMPLOYER: Name: Address: Sunny Hills Services 300 Sunny Hills Drive City: State: Zip Code: County: SIC Code: Location State: San Anselmo CA 94960 Marin CA FEIN: Type of Business (check one): Private County School District 94-1156301 State City Other Government</p><p>CARRIER: Carrier Name: Policy Begin Date: Policy End Date: Policy Number: Self-Insured? EVEREST NATIONAL INS. CO. 6600000324 Yes X No Address: City: State: Zip Code: 1111 BROADWAY OAKLAND CA 94607 Carrier FEIN: Administrator Phone Number: Administrator Name: 22-2660372 866-456-8402 Roseville Gallagher Bassett Services Address: City: State: Zip Code: P.O. Box 610 Roseville CA 95678 </p><p>EMPLOYEE: First Name: Middle Name: Last Name: Date of Birth:</p><p>Address: City: State: Zip Code:</p><p>Home Phone Number: NCCI Job Class Code: Sex: Date of Hire: State of Hire: Male Female Occupation: Marital Status: Number of Dependents: Number of Days Worked Per Week:</p><p>Employment Status: Wage Rate: Hour Year Per Week Other ______</p><p>INJURY: Date of Injury: Time of Injury: Time Employee Began Work: On Employer Premises? Were Safeguards in Place? Yes No Yes No Were they used? Yes No Date Employer Notified Date Administrator Notified: Date Disability Began: Last Date Worked: Full pay on day of Injury? Yes No Salary Continued: Yes No What was the employee doing when the injury happened? What work process was the employee involved in?</p><p>Describe the Injury (include type of injury body park involved and side of body):</p><p>What equipment, materials, etc were involved in the injury?</p><p>Location of Injury (Address, City, State, Zip):</p><p>Date Returned to Work: Date of Death (if applicable): Will employee lose time from work: Is this a Record Only report? Yes No Yes No</p><p>MEDICAL: Name and Address of Physician or Healthcare Provider: Name and Address of Medical Facility or Hospital:</p><p>Treatment (check): None Hospitalized Overnight Minor Client/Hospital Witness Name and Phone Number: Emergency Care Minor By employee Future Major Treatment/ Lost Time Anticipated</p><p>Revised 09/27/2010 ______Employer’s Signature Report Prepared By (Name & Title) Date Prepared</p><p>Revised 09/27/2010</p>