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Department of Industrial Relations DIVISION OF WORKERS' COMPENSATION -If you are injured or become ill because of your job, you are entitled to workers' compensation benefits. Complete the "Employee" section and give the form to your employer. Keep the copy marked "Employee's Temporary Receipt" until you receive the dated copy from your employer. You may contact the State's Office of Benefit Assistance and Enforcement at 1-800-736-7401 if you need help in filling out this form or obtaining your benefits. An explanation of workers' compensation benefits is included on the reverse of this form. You should also have received a pamphlet from your employer describing workers' compensation benefits and the procedures to obtain them. 1. Name Today's Date 2. Home Address 3. City 4. Date of Injury 5. Address/Place where injury happened 6. Describe injury and part of body affected 7. Signature of employee State Zip Time of Injury a.m. p.m. COMPLETE THIS SECTION AND GIVE THE EMPLOYEE A COPY IMMEDIATELY AS A RECEIPT 8. Name and address of employer 9. Policy # 11. Date employer first knew of injury 10. Employee's Soc. Sec. # 12. Was employee paid full wages for date of injury ❑ Yes ❑ No 13. Date claim form was provided to employee 14. Date employer received claim form 15. Name and address of insurance carrier or adjusting agency STATE COMPENSATION INSURANCE FUND 16. Signature of Employer Representative Date 17. Title 18. Telephone EMPLOYER: You are required to date this form and provide copies to your insurer and to the employee, dependent or representative who filed the claim within one working day of receipt of completed form from employee. Please return original along with your Employer's First Report of Injury to your local State Fund office. SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY STATE ►6NMTION DWC Form 1 (1 -1 -90) COMI N i U "ANC SCIF 3301 (Rev. 6-90) .-� - rA AAtr a q"►