<p>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</p><p>Date of this report: </p><p>Claimant: NYSIF Case#: -Unit - D/A: </p><p>Agency Name: NWI Investigative Group, Inc. Investigation Date: </p><p>Person who conducted investigation: Title: Investigator</p><p>Agency Investigation No.: NYSIF Investigation No.: </p><p>Phone Field By Appointment Preliminary report #: Final report </p><p>Employer Information:</p><p>Employer </p><p>Owner(s) / Partner(s) Name(s) </p><p>Address visited </p><p>Telephone number </p><p>Informant's name Title </p><p>Was NYSIF the Workers’ Compensation carrier on the date of accident? </p><p>If no, provide details Re: Cancellation & date </p><p>Correct carrier information as follows Check with requester if necessary to continue interview</p><p>If yes, continue interview</p><p>Nature of business </p><p>OSHA number UI registration number </p><p>Disability carrier Disability address Claimant Information:</p><p>Date of Birth Age (If less than 25-WEC62? , working papers?)</p><p>Address Phone # </p><p>Gender Race </p><p>Height Weight </p><p>Eye color Hair color </p><p>Distinguishing marks Social Security # </p><p>Is the claimant an owner/officer or related to an owner or officer? </p><p>If yes, what is the relationship? </p><p>Date of Hire Job title </p><p>Union/negotiating unit/local Department </p><p>Name of the claimant's immediate supervisor </p><p>Description of claimant's regular work duties </p><p>Claimant's regular work week Claimant's scheduled work hours </p><p>Does claimant work full or part time? </p><p>Is claimant a regular, seasonal, casual, loaned, subcontracted, independent contractor, volunteer or temporary employee? </p><p>If yes, explain </p><p>Is claimant a field worker? </p><p>If yes, explain </p><p>2 Accident Information:</p><p>Date of Accident Time of Accident </p><p>Did the accident occur on employer's premises? If yes, at which location? </p><p>If no, address where accident occurred </p><p>Description of how accident occurred </p><p>Nature of injury and body part </p><p>Object that injured claimant </p><p>Witnesses </p><p>Is a third party involved? If yes, explain </p><p>Notice:</p><p>Who gave notice? </p><p>Date and Time given? Oral or Written? </p><p>Notice given to whom? Title? Phone number? </p><p>Lost Time/Wages:</p><p>Is the claimant currently employed by policyholder? </p><p>If no, why? Separation date </p><p>Claimant's last day worked Last day paid </p><p>Was claimant paid in full for the day? If no, explain </p><p>List periods of lost time (C-11?)</p><p>Has claimant RTW? (C-11?) Date claimant RTW (C-11?)</p><p>3 Regular wages? (C-11?) If no, reduced wkly wage (C-11?)</p><p>Is/was claimant paid by employer for lost time? (C-107?)</p><p>Gross earnings for prior 52 weeks, including bonus, comm., room/board (C-240?)</p><p>Medical Treatment:</p><p>Was first aid rendered to claimant at the scene? </p><p>By whom, and to what extent? </p><p>Was claimant hospitalized? How was claimant transported? </p><p>Name of hospital </p><p>Address Phone number </p><p>Claimant was initially treated by </p><p>Primary doctor </p><p>Address Phone number </p><p>Priors: </p><p>Is employer aware of prior conditions, illnesses, injuries or accidents claimant has suffered? (Hypertension, Diabetes, Patent Defects, Eyeglasses, Contact Lenses Etc.) </p><p>If yes, explain </p><p>Did any of these involve compensation claims? </p><p>If yes, explain </p><p>Was the State Insurance Fund the carrier for any of these accidents? </p><p>If yes, explain </p><p>4 Alternate Duty:</p><p>Is light duty available? Was it offered to claimant? </p><p>Did claimant refuse or accept? </p><p>Describe the light duty </p><p>Other Benefits:</p><p>Has claimant applied for Unemployment, Disability or SSI benefits? </p><p>If yes, are they receiving benefits? Amount Start Date </p><p>Retirement Information:</p><p>Has claimant filed for retirement or otherwise indicated intent to retire at a given time/age? </p><p>If yes, type: Disability, or Regular? </p><p>Effective date </p><p>Does claimant have a pension plan? </p><p>If yes, at what age is claimant eligible to retire under pension plan? </p><p>Is employer aware of claimant seeking employment elsewhere? </p><p>Comments: Does employer have any reason to believe the claimant will abuse or take advantage of his/her workers' compensation benefits? </p><p>Does employer have any reason to dispute the accident / occurrence? </p><p>Important Evidence and Indicators </p><p>Follow up Undertaken/ Suggested </p><p>5 Any other comments? </p><p>List evidence being mailed to Point Person </p><p>Approved by: William J. Donnelly Rev 10/13 *</p><p>6</p>