Transcription of WORKERS' COMPENSATION - Applied
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WORKERS' COMPENSATION - Applied
1993-2012 ACORD CORPORATION. All rights 1 of 5 REPRINTED WITH PERMISSION OF IAIABCThe ACORD name and logo are registered marks of ACORDINITIAL TREATMENTNO MEDICAL TREATMENTMINOR: BY EMPLOYERMINOR CLINIC / HOSPEMERGENCY CAREOVERNIGHT HOSPITALIZATIONFUTURE MAJOR MEDICAL/LOST TIME ANTICIPATEDHOSPITAL OR OFFSITE TREATMENT (NAME & ADDRESS)DATE RETURN(ED) TO WORKPHYSICIAN / HEALTH CARE PROVIDER (NAME & ADDRESS)WITNESS NAME:PHONE(A/C, No, Ext):WITNESS NAME:PHONE(A/C, No, Ext):EXPOSURE OCCURREDWORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESSEXPOSURE OCCURREDSPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESSOR ILLNESS EXPOSURE OCCURREDALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENTDEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURREDDATE PREPAREDPREPARER'S NAMETITLEPHONE NUMBEROCCURRENCE / TREATMENTTYPE OF INJURY / ILLNESS CODE *PART OF BODY AFFECTED CODE *CAUSE OF INJURY CODE *DATE ADMINISTRATOR NOTIFIEDINJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILLHOW INJURY OR ILLNESS / ABNORMAL HEALTH CONDITION OCCURRED.
Page 3 of 5 Any person who, with purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as …
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