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• Employer’s 10digitUnemploymentCompensationnumber asshown on StateQuarterlyReport
• Use attachedlist todeterminecorrect code orleave blank
• Thorough formcompletion byexperiencedstaff member
• Number used by the employerto identify claim / injured employee
• Provide full nameand last knownaddress
• Employer’s mailing address(where mail is received)
• Formallyknown as SICCode
• Datephysiciantookemployee offwork
• Providecompletedetailsregarding howthe accidentoccurredincludingspecific bodypart injured
• ECMI Claim Number(leave blank)
• OSHA 300 logColumn “A”(if applicable)
EMPLOYER’S FIRST REPORT OF INJURY
• Mandatory
Injury Description CodesCause of Injury (66.)
The Employer’s First Report of Injury is a state required form used by anemployer to report work related injuries to their worker’s compensationprovider.
Injury Description CodesNature of Injury (64.)
Injury Description CodesBody (65.)Part of