<p> 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.</p><p>______Employer Name Employer Phone Number</p><p>______Employer Address City, State and Zip Code</p><p>______Department Employee’s Occupation</p><p>______Employee Name Date of Hire</p><p>______Employee Address City, State and Zip Code</p><p>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</p><p>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</p><p>How did the Injury or Exposure occur? (Please be specific, use additional sheet if necessary)</p><p>What was the source of the injury? (Part of body, machine or incident that caused the injury/exposure)</p><p>If Fatal, Give Date of Death: ______/______/______</p><p>Name and address of Physician or Facility where treated: ______</p><p>Report prepared by: ______Title: ______</p><p>Phone number: ______Date: ______</p><p>EMPLOYER’S FAILURE TO SUBMIT THIS REPORT TO INSURER IMMEDIATELY MAY RESULT IN PENALTY.</p><p>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</p>