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Black Energy Accident Report Forms


Please fill out this form in the event of an injury.

Workers Compensation-First Report of Injury or Illness
Fill out as much as you possibly can. Some fields may not be known when the event first happens but filling in as much information as is possible will speed up the claim process.

Employer( Name and Addresss Including Zip) *
Employers Location Address (If Different)
Claims Admin (Name, Address & Phone Number)
First Name *
Last Name *
Middle
Employee Address:
Employee Phone: *
Employee Date of Birth: * Pick a date
Employee SSN: *
Sex *
Marital Status *
Date Hired Pick a date
State of Hire
Occupation/ Job Title:
Employment Status
Wage Rate
Wage Rate per
# days worked/ WK
#hrs Worked per day
Date of Injury or Illness * Pick a date
Time Occurred
Time:
Last Work Date Pick a date
Full Pay for Date of Injury?
Did Salary Continue?
Date Employer Notified: * Pick a date
Date Disability Began: * Pick a date
Type of Illness/ Injury
Part of Body Affected *
Did Injury/ Illness Exposure Occur on Employer's Premisis? *
Employer Contact Name/ Phone Number *
Department or Location where accident or illness exposure occurred: *
Activity the employee was engaged in when the accident or illness exposure occurred: *
All Equipment, Materials, or Chemicals Employee was using when accident or illness exposure occurred. *
Work Process the Employee was Engaged in when accident or illness exposure occurred. *
How injury or illness/ abnormal health condition occurred. Describe the sequence of events and include any objects or substances that directly injured the employee or made the employee ill. *
Date Returned to Work: Pick a date
If Fatal, Date of Death Pick a date
Were Safeguards or Safety Equipment Provided? *
Were they used? *
Physician/ Health care provider (name & address)
Hospital (Name & Address)
Initial Treatment
Witness to Accident (Name & Phone Number)
Date Administrator Notified Pick a date
Date Prepared Pick a date
Preparer's Name & Title:
Preparer's Phone Number:
Verification:


HR