Web10 east baltimore street, baltimore, maryland 21202-1641 A copy of this form must be mailed to the DIVISION OF LABOR AND INDUSTRY, 1100 N. EUTAW STREET, SUITE … WebCOMPLETING EMPLOYEE FIRST REPORT OF INJURY . 1. Employee or an individual acting on the employee's behalf completes the Employee First Report of Injury Form. 2. …

Employee’s Report of Injury Form - Occupational Safety and …

WebA first report of injury submitted by the insurer or self-insured employer in any other manner or format is not considered filed with the division, except for a written first … WebA First Report of Injury filing with the State of Maryland is not required on a medical only claim. At Markel Service Incorporated, a servicing entity of Markel InsuranceCompany, … the prothalamion

Employer

WebIA-1 WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS Carrier/Administrator Claim Number Report Purpose Code Jurisdiction Jurisdiction Claim Number Insured Report Number Employer (Name & Address incl. zip) Location No. General Sic Code Employer FEIN Employer’s Location Address (if different) Phone No. Policy … WebTYPE OF INJURY/ILLNESS CODE This is a required filed. Enter the two-digit code that corresponds to the type of injury/illness. A list of codes can be found at: INITIAL … WebThe first day on which the claimant originally lost time from work due to the occupation injury or disease or DATE DISABILITY BEGAN: Enter the name of the individual at the employer's premises to be contacted for additional information. CONTACT NAME / PHONE NUMBER: Briefly describe the nature of the injury or illness, (eg. the protge i didnt come here for the money