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ACCIDENT REPORTING FORM FutureComp 2077 Roosevelt Avenue P. O. Box 9040 Springfield Massachusetts 01102-9040 413 781-5940 fax 413 739-9330 PLEASE PRINT OR TYPE 1. Employee Name Last First MI E M 4. Home Address No* Street City State Zip Code P L O 7. Date of Hire MM/DD/YY 8. Date of Birth MM/DD/YY Y E 11. Piece or Hourly Worker 12. Hours Worked Per Day Piece Hourly 2. Home Telephone 3. Social Security Number 5. Marital Status Single Married 9. Sex Male Female 13. Days Worked Per Week 6. No* of Dependents 10. Hourly Wage 14. Avg. 52-Week Wage Estimated or Actual 16. Employer Self-Insured Yes No 19. Employer Telephone 17. Federal Tax ID E 18. Employer Address No* Street City State Zip Code 20. Industry Code M L 21. Insurance Carrier Name and Address of Branch Responsible for This Case Not Local Agent or Adjuster O P. O. Box 9040 Springfield MA 01102-9040 R 22. Worker s Compensation Policy Number 23. OSHA Case File Number if applicable 24. Date of Injury MM/DD/YY 25. Time of Injury A. M. I N J U R 26. Source of Injury e*g* Machine Tool Substance etc* P. M. 27. Address Where Injury Occurred if different from 18 above 28. On Employer s Premises 30. Regular Occupation 33. Date Reported 32. To Whom Was Injury Reported 29. Employer Location Code 34. Nature of Injury ies Burn Fracture Cut etc* 35. Injured Body Part s Description Arm Leg Back etc* 36. Physician Name and Address F M 37. Hospital Name and Address A T O 38. Describe How Injury Occurred e*g* Struck by. Fell from*. Exposed to. 39. If Employee Has Returned to Work Date of Return 40. Returned to Regular Occupation 41. Preparer s Name Please Print or Type 43. Preparer s Signature 42. Employee Name Last First MI E M 4. Home Address No* Street City State Zip Code P L O 7. Date of Hire MM/DD/YY 8. Date of Birth MM/DD/YY Y E 11. Piece or Hourly Worker 12. Hours Worked Per Day Piece Hourly 2. Home Telephone 3. Date of Birth MM/DD/YY Y E 11. Piece or Hourly Worker 12. Hours Worked Per Day Piece Hourly 2. Home Telephone 3. Social Security Number 5. Marital Status Single Married 9. Sex Male Female 13. Days Worked Per Week 6. Social Security Number 5. Marital Status Single Married 9. Sex Male Female 13. Days Worked Per Week 6. No* of Dependents 10. Hourly Wage 14. Avg. 52-Week Wage Estimated or Actual 16. Employer Self-Insured Yes No 19. No* of Dependents 10. Hourly Wage 14. Avg. 52-Week Wage Estimated or Actual 16. Employer Self-Insured Yes No 19. Employer Telephone 17. Federal Tax ID E 18. Employer Address No* Street City State Zip Code 20. Industry Code M L 21. Employer Telephone 17. Federal Tax ID E 18. Employer Address No* Street City State Zip Code 20. Industry Code M L 21. Insurance Carrier Name and Address of Branch Responsible for This Case Not Local Agent or Adjuster O P. Insurance Carrier Name and Address of Branch Responsible for This Case Not Local Agent or Adjuster O P. O. Box 9040 Springfield MA 01102-9040 R 22. Worker s Compensation Policy Number 23. OSHA Case File Number if applicable 24. .