Employer's First Report of Injury or Fatality

THIS FORM MUST BE FILED BY THE EMPLOYER IN THE EVENT OF AN INJURY THAT RESULTS IN DEATH OR FIVE OR MORE CALENDAR DAYS OF TOTAL OR PARTIAL INCAPACITY FROM EARNING WAGES.
INSTRUCTIONS AND CODES ON THE REVERSE SIDE - Please Print Legibly or Type - Unreadable forms will be returned.

1. Employee's Name (Last, First, MI):

2. Home Telephone Number:

3. Social Security Number*:

4. Sex:

M F

5. Home Address (No., Street, City, State & Zip Code):

6. Marital Status:

M S

7. No. of Dependents:

8. Date of Hire (mm/dd/yyyy):

9. Date of Birth (mm/dd/yyyy):

10. Average Weekly Wage:

Estimated Actual

11. Employer's Name:

12. Federal Tax I.D. Number:

13. Employer's Address (No., Street, City, State & Zip Code):

14. Employer's Telephone Number:

16. Workers' Compensation Insurance Carrier and Tel. No. (NOT LOCAL AGENT/ADMINISTRATOR):

15. Industry Code (See Reverse Side):

18. Self-Insured?

Yes No If Yes, Self-Insurer Number:

17. W.C. Policy Number:

19. Business Type:

20. DATE OF INJURY (mm/dd/yyyy):

21. Was Employee Injured on Employer's Premises?

Yes No

22. Location of Injury if not on Employer's Premises:

23. FIRST day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy):

24. FIFTH day of Total or Partial Incapacity to Earn Wages (mm/dd/yyyy):

25. If Employee has Died, Date of Death (mm/dd/yyyy):

26. Source of Injury (Chemicals, Machinery, etc.):

27. Briefly Describe How Injury/Exposure Occurred and Body Part(s) involved:

28. Person to Whom Injury was Reported (list position):

29. Date Reported (mm/dd/yyyy):

30. Date Reported as work related (mm/dd/yyyy):

31. Injury Code(s) & Body Part Code(s):

Injury Code(s)

a. to body part

b. to body part

c. to body part

Body Part Code(s)

32. Witness(es) to Injury - Give Full Name(s), if none state as such:

33. Has Employee Returned to Work?

Yes No

34. Date Employee Returned to Work (mm/dd/yyyy):

35. Employee's Regular Occupation:

36. Has Employee Returned to Regular Occupation:

Yes No

37. EMPLOYER'S Name (SEE INSTRUCTIONS ON REVERSE SIDE):

38. Title:

39. EMPLOYER'S Signature (SEE INSTRUCTIONS ON REVERSE SIDE):

40. Date Prepared (mm/dd/yyyy):

The Commonwealth of Massachusetts

Department of Industrial Accidents -- Department 101