• 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