First Report of Injury or Illness

ARIZONA EMPLOYER'S REPORT OF INDUSTRIAL INJURY

Worker's Compensation Employer's First Report of Injury or Illness

Required fields for claim processing have been highlighted in yellow. The form will submit if these fields are not filled in, but the claim processing may be delayed while the missing information is collected.

EMPLOYEE

Last Name	First Name
Middle Name
Address (If unknown, type unknown)
City
State	Zip Code
Home Phone (999-999-9999)

Date of Birth

(MM/DD/YYYY)

Gender

Social Security Number
- -

Marital Status

EMPLOYER

Employer Name
Employer Address
City
State	Zip Code

Policy Number

Nature of Business

Phone #

ACCIDENT

Occupation/Job Title	Time Employee Began Work HH:MM	Date of Injury/Illness (MM/DD/YYYY)	Time of Occurrence HH:MM	Last Work Date	Date Employer Notified (MM/DD/YYYY)
Class Code on Payroll Report	Employee's Assigned Department	Department Number	Did injury/illness exposure occur on employer's premises? Yes No

Part of Body Affected

Department or location where accident or illness exposure occurred
Address

City
County
State	Zip Code

What was the Injury or Illness?


Date return(ed) to work (MM/DD/YYYY)	Fatal Yes No	If fatal, give date of death (MM/DD/YYYY)

Was Employee Treated in an Emergency Room? Yes No
Physician/Health Care Provider Name
Address

City
State	Zip Code

Was Employee Hospitalized Overnight as an In-Patient? Yes No
Hospital Name
Address

City
State	Zip Code

Validity of Claim is Doubted. State Reason.

CAUSE OF
ACCIDENT

What Happened?

What Object or Substance Directly Harmed the Employee?

What was Employee Doin Just Before the Incident Occurred?

If Another Person Not in Company Employ Caused Accident, Give Name and Address

EMPLOYEE'S
WAGE DATA

Was Worker in Your Employ When Injured?
Yes No

Hours Per Day Employee Worked
FROM AM PM
THRU AM PM

Was Employee on Overtime When Injured?
Yes No

Number of Days Per Week Usually Worked
Employee:
Company:

Date of Last Hire

Was Worker Paid for Day of Injury?
Yes No $

Was Worker Hired for Permanent Employment?
Yes No

Number of Months Employment
Available During the Year

Give Employee's Wage Status as Applicable
per

Is Employee Furnished

Value: $

Actual Gross Earnings of Employee
for the 30 Calendar Days Preceding Injury

Does Employee Claim Dependants
Yes No

If Employee Earns Extra Pay for Overtime,
What is Basis of Payment?
Per Hour

Number of Hours Overtime Considered
Normal Per Week

Gross Wages of Employee During 12 Months Preceding Injury
FROM THRU $

If Employee Worked Less Than 12 Months, Show Gross Wages From Date of Hire Through Day Prior to Injury
FROM THRU $

Date of Last Waage Increase if Within 12 Months Prior to Injury

Wage Before Increase

Wage After Increase

Gross Earnings from Date of Increase Thru Day Prior to Injury

AUTHORIZED
SIGNATURE

Date

Authorized Signature

Title