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First Report of Injury or Illness Montana Department of Labor and Industry PO Box 8011, Helena, MT 59604-8011 Employee Portion 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 Employee 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 Biweekly 13 pp 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 Employee 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 Employee Medical Information 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 Employee 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 Time of Injury na na na SIGN SIGN ---PAGE BREAK--- City of Kalispell Supervisor’s Follow-up Injury/Illness &/or Incident report Date & Time of Injury/Incident: Department(s) Involved: Date reviewed by Supervisor: Employee(s) Involved: Brief description of Incident: Supervisor’s Comments, Corrective Actions & Signature Signature of Supervisor Department Head’s Comments & Signature: Signature of Director/Chief Additional Comments: NOTE: ONCE COMPLETED, FORWARD ORIGINAL TO HUMAN RESOURCES ALONG WITH ANY SUPPORTING DOCUMENTATION SIGN SIGN ---PAGE BREAK--- City of Kalispell P.O. Box 1997 Kalispell, MT 59901 Phone: (406) 758-7757 Fax(406) 758-7758 Workers Compensation – Information for Injured Employee 1. Injury reports are to be completed and turned into the Human Resources Department immediately! Delays could result in you not being eligible for benefits! 2. Once you have filed your injury report with your Supervisor, forward the report to the Human Resources Department. 3. The Human Resources Department will then formally file the report with our Workers Compensation Adjuster Montana State Fund (MSF). 4. You will be contacted by MSF as to the status of your injury claim. 5. You will also be assigned a “claim number” which should be used anytime you are seeking treatment from a health care provider or to purchase prescriptions. 6. Advise your health care provider or pharmacist that this is a Workers Compensation Claim and the adjustor is MSF. The bills should be mailed directly to MSF. 7. Until you receive the claim number you can provide the health care provider or pharmacy with your Name, Date of Birth, Social Security Number and Date of Injury. 8. Make sure to keep your supervisor informed of the following: a. Your current health status as a result of the job-related injury or illness. b. If you have any restrictions and the duration of. c. If you are taking medications that may affect your ability to safely perform your job. d. You should always discuss with your health care provider what health effects can occur as a will result from taking prescription medications. 9. Should you have any questions about your workers’ compensation claim, you can call the City of Kalispell Human Resources Department at [PHONE REDACTED] or MSF directly at: Montana State Fund 855 Front Street Helena, MT 59601 Phone: 1 - 800 – 332-6102 ([PHONE REDACTED]) Fax: (406) 495-5020 S:\Forms\Work Comp - Information to Employee ---PAGE BREAK--- MEDICAL STATUS FORM Employer Contact Information (Optional) Revised 12/2013 Employer Copy ? Blank Space = Not Restricted (NR) Continuous Frequent Occasional Never Hand/Wrist L R B Grasping L R B Pushing/Pulling L R B Fine Manipulation L R B Reaching L R B Bending Climbing Lifting 01-10 lbs. Lifting 11-20 lbs. Lifting 21-25 lbs. Lifting 26-50 lbs. Lifting 51-70 lbs. Number of Hours Employee May: Sit Stand Walk List Other Restrictions: ? Employee Signature Date Provider Signature Date Copy of Medical Status Form to Employee Date of Next Visit Employee’s Name Date of Birth Provider (Last, First) (mm/dd/yyyy) Timestamp Date of Injury Claim Number (mm/dd/yyyy) Provider Contact Information ? Employee Released to Full Duty Employee Released to Modified Duty (See Work Abilities) Hours Per Day Employee May Work Limited Hours: Employee May Work Part-time: Employee Not Released to Work Capacity Duration (Estimate Days): 1-10 11-20 Date Date Date Date Date 21-30 To To To To To 30+ Permanent ? Released for Work? Employee Info Modified Work Abilities Signatures ---PAGE BREAK--- To the Injured Worker: On your first visit, please give this notice to any pharmacy listed on the back side to expedite the processing of your approved workers’ compensation prescriptions. (Based on the guidelines established by your employer). Questions or need assistance locating a participating retail network pharmacy? Call the Express Scripts Patient Care Contact Center at [PHONE REDACTED]. Atencion Trabajador Lesionado: Este formulario de identificación para servicios temporales de prescripción de recetas por compensación del trabajador DEBERÁ SER PRESENTADO a su farmacéutico al surtir su(s) receta(s) inicial(es). Si tiene cualquier duda o necesita localizar una farmacia participante, por favor contacte al área de Atención a Clientes de Express Scripts, en el teléfono [PHONE REDACTED]. To the Pharmacist: Express Scripts administers this occupational injury prescription program. Please follow the steps below to submit a claim. Standard claim limitations include quantity exceeding 150 pills or a day supply exceeding 14 days. This form is valid for up to 30 days from DOI. Limitations may vary. For assistance, call Express Scripts at [PHONE REDACTED]. Pharmacy Processing Steps Step 1: Enter bin number 003858 Step 2: Enter processor control A4 Step 3: Enter the group number as it appears above Step 4: Enter the injured worker’s nine-digit ID number Step 5: Enter the injured worker’s first and last name Step 6: Enter the injured worker’s date of injury (enter in DOI field in the format To the Supervisor: Please fill in the information requested for the injured worker. Thank you for using a participating retail network pharmacy. Even though there is no direct cost to you, it’s important that we all do our part to help control the rising cost of healthcare. Please see other side for a list of participating retail network pharmacies. K9HA ---PAGE BREAK--- 5th Avenue Pharmacy Albertson’s/Healthmart Albertson’s Pharmacy Anderson Family Apothecary Drug Store Baker Rexall Drug Co. Benton Pharmacy Bergum Drug, Inc Big Sky Pharmacy, Inc Billings CBOC Bitterroot Drug, Inc Bozeman Deaconess Broadway Pharmacy Castle Mountain Drug Chinook Pharmacy Choteau Drug Inc Clinic Pharmacy Cole Drug Columbus Health Mart Community Med Ctr Corvallis Drug Costco Pharmacy CVS Pharmacy Doug’s Drug Driscoll Drug Drug Mart Elkhorn Pharmacy Ennis Pharmacy Evergreen Pharmacy F&G Pharmacy Family Health Pharmacy First Pharmacy Florence Pharmacy North Gabert Clinic Pharmacy Gardiner Pharmacy Gene’s Pharmacy Good Medicine Pharmacy Granite Pharmacy Hamilton Pharmacy Healthcare Plus Highland Park Pharmacy Juro’s United Drugs KC Western Drug Keystone Drug KMart Pharmacy Lakeside Pharmacy Lee & Dad’s Pharmacy Lewistown Pharmacy Libby Drug Liberty Drug Lolo Drug Mac’s CHC Pharmacy Medical Arts Pharmacy Milk River Pharmacy Mineral Pharmacy Missoula Pharmacy Northern Montana Pharmacy Northtown Drug Olson’s Drug United Drugs Osco drug Palmers Drug Pamida Pharmacy Pharmacy 1 Pharmcare Pharmacy Pharmerica Plains Drug Plaza Pharmacy Plentywood Drug Public Drug Co. R & R Healthcare Solutions Railway Drug Remedies Pharmacy Red Lodge Drug Ridgeway Pharmacy Rosauer’s Pharmacy Safeway Pharmacy Sam’s Pharmacy Savmor Drug Seeley Swan Pharmacy Seiden Drug Company Service Drug Shopko Pharmacy Silvertip Pharmacy Smith’s Pharmacy Snyder Drugs St. Johns Pharmacy St. Joseph’s Retail Pharmacy St. Peter’s Comm Pharmacy Stillwater Family Pharmacy Stokes Pharmacy Sykes Pharmacy, Inc Target Pharmacy Three Bears Pharmacy Thrifty Drug Store Timber Ridge Pharmacy Townsend Drug VA Satellite Pharmacy Valley Drug & Variety Van’s Pharmacy Village Drug Walgreens Wal-Mart Pharmacy Westen Drug of Glasgow Western Drug of Livingston Western Drug Pharmacy Whitefish Discount Pharmacy Whitehall Drug Wolf Point Pharmacy Yellowstone Pharmacy