2007-11-28 Set Agenda - Laserfiche WebLink

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Minnesota Department of Labor and Industry Workers' Compensation Division 443 Lafayette Road North 5t. Paul, MN 55155-4305 (651) 284-5030 FIRST REPORT OF INJURY See Instructions on Reverse Side. Please PRINT or TYPE your responses. Enter dates in MM/DDfYYYY format. 111111111111111111111111111111 '" FRO 1 .,. 1. EMPLOYEE SOCIAL SECURITY # /2. OSHA Case # DO NOT USE THIS SPACE 3. DATE OF CLAIMED INJURY 14. Time of DAM 5. Time employee began DAM injury DPM work on date of injury DPM 6. EMPLOYEE Name (last, first, middle) 7. Gender 18. Marital o Married OM OF Status o Unmarried 9. Home address 10. Home phone # u111. Date of birth 1 City State Zip Code 12. Occupation 113. Regular department \14 Date hired 15. Average weekly wage 116. Rate per hour 117. Hours per day 118. Days per week 19. Employment o Full time o Part time Status o Seasonal o Volunteer 20. Weekly value of: I Meals I Lodging 2nd income 21. Apprentice DYes DNa 22. Tell us how the Injury occurred and what the employee was doing before the Incident (gIve details). Examples: 'Worker was driving lift truck with a pallet of boxes when the truck lipped, pinning worker's left leg under drive shaft," "Worker developed soreness in left wrist over time from daily computer key entry." 23. What was the Injury or illness (Include the part(s) of body)? Examples: 24. What tools, equipment, machines, objects, or substances were Involved? chemical burn left hand, broken left leg, carpal tunnel syndrome in left wrist. Examples: chiorine, hand sprayer, pallellift truck, computer keyboard. 25. Did injury occur on DYes DNo 26. Date of first day of any lost time 27. Employer paid for lost time on day of injury (DOl) employers premises? DYes ONo D No lost time on DOl If no, indicate name and address of place of 28. Date employer notified of injury 29. Date employer notified of lost time occurrence 30. Return to work date 31_ Date of death 32. TREATING PHYSICIAN (name, address, and phone) 33. HOSPITAUCLlNIC (name and address) (if any) 34. Emergency Room Visit DYes DNo 35 Overnight in-patient DYes UNO 36. EMPLOYER Legal name 37. Employer DBA name (if different) GNAW lNC Centerville Liquor Barrel 39. Employer FEIN 40. Unemployment ID # 38. Mailing address 830385468 068707550000 7093 20th Ave 41. Employer's contact name and phone # Centerville, MN 55038 43. Witness (name and phone) 42. Physical address (if different) 7093 20th Ave 44. NAICS code 45. Date form completed Centerville, MN 55038 46. INSURER name 51 CLAIMS ADMIN COMPANY (CA) name (check one) o Insurer MN Workers Compensation Assigned Risk Plan Berkley Risk Administrators Company LLC I8l TP A 47. Insured legal name 52. CA Address GNAW INC PO Box 59143 48. Policy # or self-insured certificate # City State Zip Code WC-22-04-159728-03 Minneapolis MN 55459-0143 49. Insurer FEIN 150. Date insurer received notice 53_ CA FEIN 154. Claim # 41-1429211 41-1887666 MN FR01 (09/02) Copies to: Insurer, Employer, Employee, and Woikers' Compensation Division (if no insurer) BRAe 2510 (05/03)