- Injured worker name
- Injured worker SSN
- Injured worker mailing address
- Injured worker home or work phone number
- Date of birth
- Date of injury/disease
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- Occupation or job title
- Gender
- Description of accident
- Type of injury/disease and Part(s) of body affected
- Employer policy number (look-up function provided)
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- Injured worker name
- Injured worker SSN
- Injured worker mailing address
- Injured worker home or work phone number
- Date of birth
- Date of injury/disease
- Gender
|
- Occupation or Job title
- Description of accident
- Type of injury/disease and Part(s) of body affected
- Employer policy number (look-up function provided)
- Place of accident or exposure on employer's Premises
- Date hired
- Date employer notified
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- Injured worker name
- Injured worker SSN
- Injured worker mailing address
- Injured worker home or work phone number
- Date of birth
- Date of injury/disease
|
- Causality indicator
- Gender
- Occupation or Job title
- Description of accident
- Type of injury/disease and Part(s) of body affected
- Employer policy number (look-up function provided)
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