ࡱ> #` bjbjmm .7777|8,l9L????EJ]IlK8]]]]=^4:v4n$hMOD^EOO??s U U UOFl??] UO] U UXl,Y?`9 ju87 P:wYsZT0YۓDPۓ4YۓYMvwMT UMDNMMMUMMMOOOO77 EMPLOYERS FIRST REPORT OF INJURY OR DISEASE  The provision of your social security number is voluntary. Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)]. (Please read the instructions on page 2 for completing this form) Employee Name (First, Middle, Last)  FORMTEXT      Social Security Number  FORMTEXT     -  FORMTEXT    -  FORMTEXT     Sex  FORMCHECKBOX  M  FORMCHECKBOX  FEmployee Home Telephone No. ( FORMTEXT    )  FORMTEXT     -  FORMTEXT     Employee Street Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      - FORMTEXT     Occupation  FORMTEXT      Birthdate  FORMTEXT      Date of Hire  FORMTEXT      County and State Where Accident or Exposure Occurred?  FORMTEXT      Employer Name  FORMTEXT University of Wisconsin MilwaukeeWI Unemployment Ins. Acct No.  FORMTEXT 6911180002 Self-Insured?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  Nature of Business (Specific Product)  FORMTEXT Higher EducationEmployer Mailing Address  FORMTEXT P.O. Box 413City  FORMTEXT MilwaukeeState  FORMTEXT WIZip Code  FORMTEXT 53201- FORMTEXT 0413Employer FEIN  FORMTEXT 39 -  FORMTEXT 6006492Name of Workers Compensation Insurance Co. or Self-Insured Employer  FORMTEXT University of Wisconsin System (OSLP) State of WisconsinInsurer FEIN  FORMTEXT 39 -  FORMTEXT 6006492Name and Address of Third Party Administrator (TPA) Used by the Insurance Company or Self-Insured Employer  FORMTEXT N/ATPA FEIN  FORMTEXT NA -  FORMTEXT      Wage at Time of Injury $  FORMTEXT       .Specify per hr., wk., mo., yr., etc. Per:  FORMTEXT       In Addition to Wages,  FORMCHECKBOX  Meals No. of Meals/wk.  FORMTEXT       Check Box(es) if  FORMCHECKBOX  Room No. of Days/wk  FORMTEXT   Employee Received:  FORMCHECKBOX  Tips Avg. Weekly Amt. $  FORMTEXT      Is Worker Paid for Overtime?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes, After How Many Hours of Work Per Week?  FORMTEXT      For the 52 Week Period Prior to the Week the Injury Occurred, Report Below the Number of Weeks Worked in the Same Kind of Work, and the Total Wages, Salary, Commission and Bonus or Premium Earned for Such Weeks.No. of Weeks:  FORMTEXT   Gross Amount Excluding Tips: $  FORMTEXT      If Piece-Work, No. of Hrs. Excluding Overtime:  FORMTEXT      Start TimeHours Per DayHours Per WeekDays Per WeekEmployee s Usual Work Schedule When Injured: FORMTEXT   :  FORMTEXT     FORMCHECKBOX  AM  FORMCHECKBOX  PM FORMTEXT       FORMTEXT       FORMTEXT  Employer s Usual Full-Time Schedule for This Type of Work at Time of Employee s Injury: FORMTEXT       FORMTEXT       FORMTEXT  Part-Time Employment Information:Are there Other Part-Time Workers Doing the Same Work With the Same Schedule?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, how many?  FORMTEXT      Number of Full-Time Employees Doing The Same Type Of Work:  FORMTEXT      Injury Date  FORMTEXT      Time of Injury  FORMTEXT   :  FORMTEXT    AM  FORMTEXT   :  FORMTEXT    PMLast Day Worked  FORMTEXT      Date Employer Notified  FORMTEXT       FORMCHECKBOX  Date Returned to Work  FORMTEXT        FORMCHECKBOX  Estimated Date of Return  FORMTEXT      Did Injury Cause Death?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoDate of Death  FORMTEXT      Was This a Lost Time or Other Compensable Injury?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoDid Injury Occur Because of:  FORMCHECKBOX  Substance  FORMCHECKBOX  Failure to Use  FORMCHECKBOX  Failure to Abuse Safety Devices Obey RulesWas Employee Treated in an Emergency Room?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Was Employee Hospitalized Overnight as an In-Patient?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Name and Address of Treating Practitioner and Hospital:  FORMTEXT       Case Number from the OSHA Log:  FORMTEXT      Injury Description - Describe Activities of Employee When Injury or Illness Occurred and What Tools, Machinery, Objects, Chemicals, Etc. Were Involved.  FORMTEXT       What Happened to Cause This Injury or Illness? (Describe How The Injury Occurred)  FORMTEXT       What Was the Injury or Illness? (State the Part of Body Affected and How It Was Affected)  FORMTEXT       Report Prepared By  FORMTEXT      Work Phone Number ( FORMTEXT    )  FORMTEXT     -  FORMTEXT     Position  FORMTEXT      Date Signed  FORMTEXT      WKC-12-E (R. 11/2005)SEND REPORT IMMEDIATELY - DO NOT WAIT FOR MEDICAL REPORT EMPLOYER AND INSURANCE CARRIER INSTRUCTIONS The employer must complete all relevant sections on this form and submit it to the employers workers compensation insurance carrier or third party claim administrator within seven (7) days after the date of a work-related injury which causes permanent or temporary disability resulting in compensation for lost time. 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For any work injury resulting in a fatality, the employer must also submit this form directly to the Department of Workforce Development within 24 hours of the fatality. An employer exempt from the duty to insure under s. 102.28, Wis. Stats., and an insurance carrier administering claims for an insured employer are required to submit this form to the Department of Workforce Development within 14 days of the date of work injury. MANDATORY INFORMATION In order to accurately administer claims, each of the following sections of this form must be completed. The First Report of Injury will be returned to the sender if the mandatory information is not provided. Employee Section: Provide all requested information to identify the injured employee. If an employee has multiple dates of employment, the  Date of Hire is the date the employee was hired for the job on which he or she was injured. Employer Section: Provide all requested information to identify the injured worker s employer at the time of injury. Provide the name and Federal Employer Identification Number (FEIN) for the insurance carrier or self-insured employer responsible for the worker s compensation expenses for this injury. Also identify the third party claim administrator, if one is used for this claim. Wage Information Section: Provide the information requested regarding the injured employee s wage and hours worked for the job being performed at the time of injury. Injury Information Section: Provide information regarding the date and time of injury. Provide a detailed description of the injury, including part of the body injured, the specific nature of the injury (i.e., fracture, strain, concussion, burn, etc.) and the use of any objects or tools (i.e., saw, ladder, vehicle, etc.) that may have caused the injury. Provide the name of the person preparing this report and the telephone number at which they may be reached, if additional information is needed. This form was designed to include information required by OSHA on form 301. If this section is completed and retained, the employer will not have to complete the OSHA 301 form. Department of Workforce Development Worker s Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Imaging Server Fax: (608) 260-2503 Telephone: (608) 266-1340 http://www.dwd.state.wi.us/wc/ e-mail: DWDDWC@dwd.state.wi.us INJURY INFORMATION WAGE INFORMATION EMPLOYER EMPLOYEE L O Y E R W A G E I N F O R M A T I O N I N J U R U Y I N F O R M A T I O N Fatal Injuries: Employers subject to ch.102, Wis. Stats., must report injuries resulting in death to the Department and to their insurance carrier, if insured, within one day after the death of the employee. Non-Fatal Injuries: If the injury or occupational illness results in disability beyond the three-day waiting period, the employer, if insured, must notify its insurance carrier within 7 days after the injury or beginning of disability. Medical-only claims are to be reported to the insurance carrier only, not the Department. Electronic Reporting Requirement: All work-related injuries and illnesses resulting in compensable lost time, with the exception of fatalities, must be reported electronically to the Department via EDI or Internet by the insurance carrier or self-insured employer within 14 days of the date of injury or beginning of disability. Employer may fax claims for fatal injuries to the Imaging Fax Server number on this form. 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