First Report of Injury

• Audit Title

• Employer's FEIN

Employers Name

• Consolidated Waterproofing Contractors, Inc.

Doing Business As

• Consolidated Waterproofing Contractors, Inc.

Employer's mailing address

• 10732 Hanna St., Beltsville, MD 20705

Name of workers' compensation carrier/admin.

Policy/Contract #

• Self Insured?

  Yes

  No

Employee Info

• Employee's full name

• Social Security #

• Birthdate

  Date

• Employee's mailing address

• Employee's e-mail address

• Male or Female?

  Male

  Female

• Married or Single?

  Married

  Single

• # Dependents

• Employee's average weekly wage

• Job title or occupation

• Date Hired

  Date

• Time employee began work

  Date

• Date and time of accident

  Date

• Last day employee worked

  Date

• If the employee died as a result of the accident, give the date of death.

  Date

• Did the accident occur on the employer's premises?

  Yes

  No

• Address of accident

• What was the employee doing when the accident occurred?

• How did the accident occur?

• What was the injury or illness? List the part of body affected and explain how it was affected.

• What object or substance, if any, directly harmed the employee?

• Name and address of physician/health care professional

• If treatment was given away from the worksite, list the name and address of the place it was given.

• Was the employee treated in an emergency room?

  Yes

  No

• Was the employee hospitalized overnight as an inpatient?

  Yes

  No

• Report prepared by/title.

• Signature

  Sign