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First Report of Injury or Occupational Disease Montana Department of Labor and Industry PO Box 8011, Helena, MT 59604-8011 Worker Last Name First Name M.I. Date of Birth Social Security Number Mailing Address City State Postal Code Phone Number Education Less Than High School GED or High School Diploma Beyond High School Gender Male Female Unknown Marital Status Married Separated Widowed, Divorced, Single, Unmarried Unknown Number of Dependents Wages Date Hired Gross earnings for four pay periods preceding the injury Date/Amount / Date/Amount / Date/Amount / Date/Amount / Employment Status Full-Time Part-Time Piece Worker Seasonal Volunteer Other Number of Days worked per week Wage Wage Period Hour Week Month Day Bi-Weekly In addition to gross earnings cited above worker received Estimated value if any Room & Board Overtime Bonus Commissions Other: Time Employee began work Worked next scheduled shift Yes No Off work more than 4 work days Yes No Not Sure Date Last Worked Date of Return to Work Full wages paid for date of injury Yes No Salary Continued Yes No Accident Description Job Title Description of Accident Cause of Injury Cause Code Part of Body Part Code Nature of Injury Nature Code Date of Injury Time of Injury Date Disability Began Date of Death Names of Witnesses 1) 2) 3) Accident on Employer’s Premises Yes No Accident Address or Location City State Postal code Date Employer Notified Accident Reported to Safety Equipment Provided Yes No Safety Equipment Used Yes No Medical Attending Physician’s Name Address State Postal Code Phone Number Hospital Name Address State Postal Code Phone Number Type of initial medical treatment received No Treatment Emergency Room/Urgent Care Treatment on-site by Employer or Medical Staff Clinic/Dr. Office Hospital > 24 hours Signature “This is my claim for workers’ compensation benefits due to the on-the-job injury, occupational disease, or death of the above named worker. I understand that signing this claim for compensation authorizes the release to the workers’ compensation insurer (and its agents) and to the Montana Uninsured Employers’ Fund of: Social Security records; rehabilitation records; and all health care information (medical records, pursuant to HIPAA, Public Law 104-191, 42 USC section 1301, et. seq., and section 39-71-604, MCA), that are directly relevant to the claimed injury, disease, or death. I also understand that if I obtain or exert unauthorized control over workers’ compensation benefits to which I am not entitled, I may be prosecuted for theft.” Signature of Injured Worker or Beneficiary Date: Employer Employer Name Doing Business as Federal Employer Identification Number (Tax I.D) Mailing Address City State Postal Code Phone Number Location of operation, if different from mailing address Nature of Business SIC/NAICS Code Self-Insured Yes No Employer is a Sole Proprietorship Partnership Corporation Limited Liability Company Injured worker is a Sole Proprietorship Partnership Corporation Limited Liability Company A member of the employer’s (sole proprietor) family living in the employer’s household. Do you have any reason to question this accident? Yes No If yes, please explain fully. Use separate sheet if you need additional space Was worker injured while in your employ Yes No Prepared By Official Title Phone Number Date Payroll Classification Code under which you report Employee’s wages Date Authorized Employer’s Signature Insurer Claim Administrator Claim Number Date Reported to Claim Administrator: The above information is correct with the following exceptions (Attach extra sheets if box at right is checked) Claim Administrator Name Claim Administrator Address Claim Administrator FEIN Insurer Name Insurer FEIN Policy Number Policy Effective Date Policy Expiration Date ERD – 991 (Rev. 05/2016 DE) OSHA Log Case # Adjuster Date Stamp