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NATURE OF INJURY PART OF BODY CAUSE OF INJURY 01. No Physical Injury 10. Multiple Head Injury 01. Chemicals 02. Amputation 11. Skull 02. Hot Objects or Substances 03. Angina Pectoris 12. Brain 03. Temperature Extremes 04. Burn 13. Ear(s) 04. Fire or Flame 07. Concussion 14. Eye(s) 05. Steam or Hot Fluids 10. Contusion 15. Nose 06. Dust, Gases, Fumes or Vapors 13. Crushing 16. Teeth 07. Welding Operation 16. Dislocation 17. Mouth 08. Radiation 19. Electric Shock 18. Soft Tissue 09. Contact With, NOC. 22. Enucleation 19. Facial Bones 10. Machine or Machinery 25. Foreign Body 20. Multiple Neck Injury 11. Cold Objects or Substances 28. Fracture 21. Vertebrae 12. Object Handled 30. Freezing 22. Disc 13. Caught In, Under or Between, NOC. 31. Hearing Loss or Impairment 23. Spinal Cord 14. Abnormal Air Pressure 32. Heat Prostration 24. Larynx 15. Broken Glass 34. Hernia 25. Soft Tissue 16. Hand Tool, Utensil; Not Powered 36. Infection 26. Trachea 17. Object Being Lifted or Handled 37. Inflammation 30. Multiple Upper Extremities 18. Powered Hand Tool, Appliance 40. Laceration 31. Upper Arm 19. Caught, Puncture, Scrape, NOC. 41. Myocardial Infarction 32. Elbow 20. Collapsing Materials (Slides of Earth) Either Man Made or Natural 42. Poisoning - General 33. Lower Arm 25. From Different Level (Elevation) Off Wall, Catwalk, Bridge, Etc. 43. Puncture 34. Wrist 26. From Ladder or Scaffolding 46. Rupture 35. Hand 27. From Liquid or Grease Spills 47. Severance 36. Finger(s) 28. Into Openings Shafts, Excavations, Floor Openings, Etc. 49. Sprain or Tear 38. Shoulder(s) 29. On Same Level 52. Strain or Tear 39. Wrist & Hand(s) 30. Slipped, Do Not Fall 53. Syncope 40. Multiple Trunk 31. Fall, Slip or Trip, NOC. 54. 41. Upper Back Area 32. On Ice or Snow 55. Vascular 42. Lower Back Area 33. On Stairs 58. Vision Loss 43. Disc 40. Crash of Water Vehicle 59. All Other Specific Injuries, NOC 44. Chest 41. Crash of Rail Vehicle 60. Dust Disease, NOC 45. Sacrum and Coccyx 45. Collision or Sideswipe With Another Vehicle 61. Asbestosis 46. Pelvis 46. Collision with a Fixed Object Standing Vehicle or Stationary Object 62. Black Lung 47. Spinal Cord 47. Crash of Airplane 63. Byssinosis 48. Internal Organs 48. Vehicle Upset Overturned or Jackknifed 64. Silicosis 49. Heart 50. Motor Vehicle, NOC. 65. Respiratory Disorders 50. Multiple Lower Extremities 52. Continual Noise 66. Poisoning - Chemical, (Other Than Metals) 51. Hip 53. Twisting 67. Poisoning - Metal 52. Upper Leg 54. Jumping 68. Dermatitis 53. Knee 55. Holding or Carrying 69. Mental Disorder 54. Lower Leg 56. Lifting 70. Radiation 55. Ankle 57. Pushing or Pulling 71. All Other Occupational Disease Injury, NOC 56. Foot 58. Reaching 72. Loss of Hearing 57. Toes 59. Using Tool or Machinery 73. Contagious Disease 58. Big Toes 60. Strain or Injury By, NOC. 74. Cancer 60. Lungs 61. Wielding or Throwing 75. AIDS 61. Abdomen Including Groin 65. Moving Part of Machine 76. VDT - Related Diseases 62. Buttocks 66. Object Being Lifted or Handled 77. Mental Stress 63. Lumbar & or Sacral Vertebrae 67. Sanding, Scraping, Cleaning Operation 78. Carpal Tunnel 64. Artificial Appliance 68. Stationary Object 79. Hepatitis C 65. Insufficient Info to Properly Identify 69. Stepping on Sharp Object 80. All Other Cumulative Injury, NOC 66. No Physical Injury 70. Striking Against or Stepping On, NOC. 90. Multiple Physical Injuries Only 90. Multiple Body Parts 74. Fellow Worker; Patient 91. Multiple Injuries Including Both Physical & 91. Body Systems and Multiple Body 75. Falling or Flying Object 99. Whole Body 76. Hand Tool or Machine in Use 77. Motor Vehicle 78. Moving Parts of Machine 79. Object Being Lifted or Handled 80. Object Handled By Others 81. Struck or Injured, NOC. 82. Absorption, Ingestion or Inhalation, NOC 84. Electrical Current 85. Animal or Insect 86. Explosion or Flare Back 87. Foreign Matter (Body) in Eye(s) 88. Natural Disasters 89. Person in Act of a Crime 90. Other Than Physical Cause of Injury 91. Mold 94. Repetitive Motion Callous, Blister, Etc. 95. Rubbed or Abraded, NOC. 96. Terrorism 97. Repetitive Motion Carpel Tunnel 98. Cumulative, NOC INSTRUCTIONS FOR FILING WC FIRST REPORT OF INJURY Employers should send a completed legible form to the insurance carrier or, if self-insured, to the designated office handling their workers’ compensation claims. The insurance carrier or designated office should forward this First Report on to the Workers’ Compensation Division, Department of Industrial Relations, Montgomery, Alabama 36131 within fifteen (15) days from the date of injury or date of notification to the employer for all injuries for which compensation is claimed or paid. This includes deaths, permanent disabilities or temporary disabilities exceeding three days). Block 1. A number assigned by the insured to identify a specific claim Block 2. An identifier for a specific claim within a claim administrator’s claims processing system. Block 3. Case number from log maintained for OSHA Block 4 - Block 14. Self Explanatory Block 15. Employer Federal ID number Block 16. Employer Unemployment Compensation Account Number Block 17. NAICS Industry Codes http://dir.alabama.gov/docs/forms/wc_naics.pdf Block 18. Carrier’s name Block 19. Carrier’s FEIN Block 20. A code representing the kind of entity providing financial responsibility for the claim, exp: ( I ) Insurance Carrier Self Insurer Guarantee Fund/Group Block 21 through Block 63. Self Explanatory Block 64. Nature of Injury Codes http://dir.alabama.gov/docs/forms/wcio_nature_table.pdf Block 65. Part of Body Codes http://dir.alabama.gov/docs/forms/wcio_part_table.pdf Block 66. Cause of Injury Codes http://dir.alabama.gov/docs/forms/wcio_cause_table.pdf Block 67 through Block 81. Self Explanatory 99. Other - Miscellaneous, NOC