EMPLOYER’S FIRST REPORT OF OCCUPATIONAL INJURY OR DISEASE
(Note:  the DN Numbers represent a crosswalk to the IAIABC Claims Release 3 EDI data elements.)	
1. WCB FILE NUMBER  (if  known):
DN5	
	
1a. OSHA 300 CASE NUMBER  (if applicable):
NA	
REASON FOR REPORT (check all that apply)	
2a. o LOST TIME - ONE OR MORE DAYS        DN74  2b.     WAS EMPLOYEE PAID FOR ½ DAY OR MORE ON DAY OF INJURY?	o YES	o NO  DN66
3.   o LOST EARNINGS BUT NO LOST TIME   NA        4.      o MEDICAL/HEALTH CARE DN74	                   5.    o FATALITY DATE OF DEATH:     _____/_____/_____   DN57                                       
                                                                                                                                                                                                                            Also see DN146         MM     DD    YYYY
6a. o OCCUPATIONAL DISEASE   DN290                   6b.     DATE OF LAST EXPOSURE:   _____/_____/____ DN31 6c.  DATE OF DIAGNOSIS AS OCCUPATIONALLY RELATED:  ____/_____/_____   NA         			 		                                                                  MM    DD     YYYY		                                                                              MM    DD    YYYY 
7a. o CORRECT PRIOR REPORT   DN2                        7b.     DATE OF CORRECTION:  _____/_____/_____   DN3      7c.  DATE CORRECTION SENT TO WCB:  _____/_____/_____  DN3   
           Note: also see correction process & DN295, 296                                MM      DD    YYYY	                                                                                           MM     DD    YYYY	
	
8. STATE EMPLOYER UNEMPLOYMENT 
INSURANCE ACCOUNT NUMBER (UIAN): DN329	9. FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): DN16	10. EMPLOYER NAME:   DN18	
11. STREET/P.O BOX MAILING ADDRESS:
DN168-169	12. CITY: DN165	13. STATE:  DN170	14. ZIP:  DN167	15. TELEPHONE NUMBER:  DN159
(	)	
16. PRIMARY BUSINESS PERFORMED BY 
EMPLOYER WHERE INJURY OCCURRED: 
 DN25	17. EMPLOYER LOCATION IF DIFFERENT FROM MAILING ADDRESS: 
DN19-23
EMPLOYER PHYSICAL COUNTRY 
CODE = DN164	18. DID INJURY OR EXPOSURE OCCUR ON EMPLOYER’S PREMISES? o YES  o NO                                                                                                        
                                                                                                                               DN249
IF NO, THEN GIVE NAME AND PHYSICAL ADDRESS OF THE EMPLOYER WHERE THE EMPLOYEE WAS INJURED OR EXPOSED:  DN120; 119, 122, 121, 123, 33, 118 
ACCIDENT SITE COUNTRY CODE = DN280
	
(check one)  o  INSURER		                          o  THIRD PARTY ADMINISTRATOR (TPA)		          o  SELF-ADMINISTERED EMPLOYER	
19. INSURANCE / TPA COMPANY NAME:
DN7/188	20. POLICY NUMBER: 
DN28	21. INSURER FILE NUMBER: DN15	
22. STREET/P.O. BOX MAILING ADDRESS:
DN10-11	23. CITY:  DN12	24. STATE: DN13	25. ZIP: DN14	26. TELEPHONE NUMBER: 
       (            ) NA	
	
27. LAST NAME: DN43 & DN255	28. FIRST NAME: DN44	29. MI: 
DN45	30. TELEPHONE NUMBER:
(	) DN51	31. SOCIAL SECURITY NUMBER:
DN42	32. GENDER: DN53
o MALE  o  FEMALE	
33. STREET/P.O. BOX MAILING ADDRESS:
DN46-47	34. CITY:  DN48	35. STATE: DN49	36. ZIP: DN50	37. DATE OF BIRTH:  DN52

_____/_____/_____
 MM    DD     YYYY	
38. OCCUPATION/JOB TITLE:  DN60
	39. DATE OF HIRE: DN61

   _____/_____/_____ 
   MM     DD      YYYY	40. WEEKLY WAGE AT TIME OF INJURY:

$  DN62	41. DOES EMPLOYEE WORK FOR ANOTHER EMPLOYER?
oYES o  NO     IF YES, GIVE NAME AND ADDRESS: 

NA	
CLAIM INFORMATION	
42. DATE OF INJURY OR ILLNESS:

_____/_____/_____ DN31
 MM    DD     YYYY

DATE EMPLOYER NOTIFIED:

_____/_____/_____ DN40
  MM   DD	  YYYY	43. DATE OF INCAPACITY:

_____/_____/_____ DN56
 MM     DD    YYYY

DATE EMPLOYER NOTIFIED:

_____/_____/____  DN281
  MM    DD    YYYY	44. TIME EMPLOYEE BEGAN WORK
 (e.g. 7:30 a.m.):
NA
	45. DATE EMPLOYER NOTIFIED INSURER/TPA:

_____/_____/_____  DN41
 MM     DD    YYYY	
		46. TIME OF INJURY (e.g. 1:10 p.m.): 
      DN32	47. HAS EMPLOYEE RETURNED TO WORK? o YES o NO DN 189

 IF YES, GIVE DATE:  _____/_____/_____ DN68
	               MM     DD    YYYY	
48. SPECIFIC INJURY OR ILLNESS 
(e.g. second degree burn or toxic hepatitis): 
    DN35	49. BODY PART(s) AFFECTED (e.g. lower right forearm): 
     DN36	 50. ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS 
 USING WHEN THE EVENT OCCURRED (e.g. acetylene torch, metal plate): 
      DN37	
51. SPECIFY ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE EVENT OCCURRED (e.g. cutting metal plate for flooring.):

NA

WAS ACTIVITY PART OF NORMAL JOB DUTIES? o YES o NO	52. HOW INJURY OR ILLNESS OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED OR MADE THE EMPLOYEE ILL. (e.g. worker stepped back to inspect work and 
slipped on some scrap metal. As worker fell, worker brushed against hot metal.):  DN38	
53. HOSPITALIZED OVERNIGHT AS INPATIENT?
o YES o NO DN39

	54. WAS THE EMPLOYEE TREATED IN AN EMERGENCY ROOM?
o YES o NO: DN39
	55. HEALTH CARE PROVICER NAME: 

DN209
	56.  MAILING ADDRESS:

NA	57. TELEPHONE NUMBER:
  (	) NA  	
PREPARER INFORMATION	
58. PREPARER NAME AND TITLE (TYPE OR PRINT):
NA	59. TELEPHONE NUMBER:
      (        ) NA	60. DATE SENT TO WCB: DN100
                                                _____/_____/_____
  MM     DD    YYYY	
WCB-1 (01/02)     The State of Maine does not discriminate on the basis of disability in admission to, access to, or operation of its programs, services or activities. This material can be made available in alternate formats by contacting your Department ADA Coordinator.
DISTRIBUTION:  COPY (1) MAINE WORKERS’ COMPENSATION BOARD, 27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027, (2) EMPLOYEE, (3) INSURER, (4) EMPLOYER.