| Email Address:* |
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| Injured Employee Information |
| Last Name:* |
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| First Name:* |
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| Middle Initial: |
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| Social Security Number:* |
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| Home Phone:* |
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| Date of Birth (mm/dd/yyyy):* |
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| Does the Employee Speak English?:* |
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| If No, Specify Language: |
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| Race:* |
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| Mailing Address:* |
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| City:* |
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| State:* |
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| Zip Code:* |
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| County:* |
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| Marital Status:* |
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| Number of Dependent Children:* |
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| Spouse's Name: |
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| Provider Information |
| Doctor's/Hospital Name: |
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| Mailing Address (Street or P.O. Box): |
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| City: |
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| State: |
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| Zip Code: |
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| Date of Injury (mm/dd/yyyy):* |
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| Time of Injury (ex: 02:30pm):* |
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| Date Lost Time Began (mm/dd/yyyy):* |
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| Nature of Injury:* |
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| Part of Body Injured or Exposed:* |
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| How and Why Injury/Illness Occurred:* |
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| Was employee doing his regular job?:* |
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| Worksite Location of Injury (stairs, dock, etc.):* |
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| Address Where Injury or Exposure Occurred (If incident occurred on a business site, include business name): |
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| City: |
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| State: |
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| Zip Code: |
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| Cause of Injury (fall, tool, machine, etc.):* |
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| List Witnesses:* |
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| Return to Work date/or expected (mm/dd/yyyy):* |
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| Did Employee die?:* |
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| Supervisor's Name:* |
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| Date Reported (mm/dd/yyyy):* |
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| Date of Hire (mm/dd/yyyy):* |
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| Was employee hired or recruited in Texas?:* |
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| Length of Service in Current Position (Months and Years):* |
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| Length of Service in Occupation (Months and Years): |
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| Employee Payroll Classification Code: |
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| Occupation of Injured Worker:* |
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| Rate of Pay at this Job (Hourly or Weekly):* |
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| Full Work Week is (Hours or Days):* |
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| Last Paycheck was (Amount and include hours/days): |
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| Is Employee an Owner, Partner, or Corporate Officer?:* |
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| Name and Title of Person Completing Form:* |
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| Name of Business:* |
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| Business Mailing Address:* |
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| City:* |
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| State:* |
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| Zip Code:* |
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| Business Telephone:* |
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| Business Location (if different from mailing address) Number and Street: |
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| City: |
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| State: |
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| Zip Code: |
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| Federal Tax Identification Number:* |
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| Primary North American Industry Classification System Code (6 digit): |
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| Specific NAICS Code (6 digit): |
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| Texas Comptroller Taxpayer No.: |
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| Workers' Compensation Insurance Company:* |
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| Policy Number:* |
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| Did You request accident prevention services in past 12 months?: |
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| If Yes, did you receive them?: |
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| By initialing here you indicate all information is correct to the best of your knowledge:* |
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| Today's Date (mm/dd/yyyy):* |
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