Information
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Audit Title
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Employer's FEIN
Employers Name
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Pete's Fresh Market
Doing Business As
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Pete's Market, Inc.
Employer's mailing address
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4333 S. Pulaski Rd.
Name of workers' compensation carrier/admin.
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PMA Companies
Policy/Contract #
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0431247
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Self Insured?
Employee Info
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Employee's full name
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Social Security #
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Birthdate
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Employee's mailing address
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Employee's e-mail address
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Male or Female?
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Married or Single?
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# Dependents
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Employee's average weekly wage
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Job title or occupation
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Date Hired
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Time employee began work
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Date and time of accident
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Last day employee worked
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If the employee died as a result of the accident, give the date of death.
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Did the accident occur on the employer's premises?
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Address of accident
- PFM #01 - 57th & Kedzie
- PFM #02 - 47th & Kedzie
- PFM #03 - 43rd & Pulaski
- PFM #04 - West Lawn Market
- PFM #05 - 118th & Ave O
- PFM #06 - Cermak & Rockwell
- PFM #07 - Calumet City
- PFM #08 - Evergreen Park
- PFM #09 - Oakbrook Terrace
- PFM #10 - Madison & Western
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What was the employee doing when the accident occurred?
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How did the accident occur?
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What was the injury or illness? List the part of body affected and explain how it was affected.
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What object or substance, if any, directly harmed the employee?
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Name and address of physician/health care professional
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If treatment was given away from the worksite, list the name and address of the place it was given.
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Was the employee treated in an emergency room?
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Was the employee hospitalized overnight as an inpatient?
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Report prepared by/title.
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Signature
