City county insurance services




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CITY COUNTY INSURANCE SERVICES

WORKERS’ COMPENSATION CLAIMS

P.O. Box 1469

Lake Oswego, OR 97035

Telephone: (503) 763-3875



Fax: (503) 763-3901

EMPLOYER’s report

of occupational injury or disease/illness

NOTE: This form satisfies OSHA Form 301 record-keeping requirements. Complete only this page (Page 1) if the worker is not filing a claim. If the worker completes Page 2 and files a workers’ compensation claim, attach a copy of this form and send both to your insurer within five days of notice or knowledge of a claim.

1.Worker’s name, mailing address, and phone:

     

2. Date of birth:

     

3. Male Female

 

4. SSN:

     

5. Date of hire:

     

6. State of hire:

Oregon

7. Payroll class code:

     

8. Employer’s name:

City of Albany, Oregon

9. Insurance policy no.:

------------

10. Employer FEIN:

93-6002114

11. Immediate supervisor’s phone no.:

(     )     

12. Personnel phone number:

(541) 917-7500

13. Nature of employer’s business:

Municipality

14. Department and street address where event occurred:

a. Department Code:
b. Injury Address:


15. Name and address of medical office (if treated away from work site):

     

16. Street address of worker’s normal workplace, if different from #14:

     

17. Name of worker’s doctor or other health-care professional:

     

18. Employer’s business address, if different from #14 or #16:

c/o HR Department, P.O. Box 490, Albany, OR 97321

23. Was worker treated in an emergency room?  Yes  No

24. Was worker hospitalized overnight as inpatient?  Yes  No

25. Did injury occur during course of job? Unknown  Yes  No

26. Was injury caused by person other than injured worker?  Yes  No

27. Was injury caused by failure of machinery or product?  Yes  No

28. Were other workers injured?  Yes  No

29. Is worker an owner or corporate officer?  Yes  No

30. Is worker “premium exempt” (a Preferred Worker)?  Yes  No

(If “Yes,” attach copy of eligibility card or “Notice of Premium Exemption.”)

19. Injury occurred:  On employer’s premises

 On client’s premises (if leased/temp worker)

 Off premises  At unknown location

20. Client’s name, if employer is leasing co. or temporary agency:

     

21. Client phone:

     

22. Client FEIN:

     

31. Scheduled days off:

32. No. of days worked per week:

     

33. Wage & wage period:

Per  Hr  Day

 Wk. Mo  Yr















$

     




S

S

M

T

W

T

F

34. Hours per shift:      

Give total weekly wage and explain if wage prior to injury varied or included other earnings (tips, room and board, commission, etc.) Attach 52 weeks of payroll records.      

35. Date left work:

     

36. Time left work:

       a.m.  p.m.

37. Return-to-work status:

 Not returned

 Regular – Date:      

 Modified – Date:      

If returned to modified work,

is it at regular hours and

wages?  Yes  No

Employer: Do not release data above this line except as required or allowed by U.S. or Oregon laws. Under OAR 437-001-

0700(20)(e), data BELOW this line must be released to the worker’s collective-bargaining-agreement representative upon request.

38. Describe how the incident/injury occurred, including the worker’s activity, tools, equipment, and materials involved. Describe the injury or

illness, including part of body affected and object or substance involved. Example: “Climbing a ladder while carrying roofing materials. Ladder slipped on wet floor and worker fell twenty feet to concrete floor and broke his shoulder.”      

39. Worker’s shift on day of injury (from)        a.m.  p.m.

(to)        a.m.  p.m.

40. Date of injury or illness:

     

41. Time of injury or illness:

       a.m.  p.m.

42.

X            




43. If fatal, date of death:

     

Employer’s signature Date

44. Print name, title, and phone number of signer:

Laura Hyde, Executive Assistant to the City Manager, (541) 917-7508

45. OSHA log case number:

     

Attention: Report fatalities or catastrophes to DCBS/OR-OSHA within eight hours of occurrence. Call toll-free in Oregon (800) 922-2689 or (503) 378-3272. Report accidents that result in overnight hospitalization with medical treatment to the DCBS/OR-OSHA local field office within 24 hours of employer notification. At night or on weekends, call Oregon Emergency Response, (800) 452-0311.

440-801 (12/01/DCBS/WCD/WEB)

Oregon Workers’ Compensation Division Page 1 of 2

801



Text in yellow: Department Representative Text in green: HR Department


CITY COUNTY INSURANCE SERVICES

WORKERS’ COMPENSATION CLAIMS

P.O. Box 1469

Lake Oswego, OR 97035

Telephone: (503) 763-3875

Fax: (503) 763-3901


WORKER’s report

of occupational injury or disease/illness claim




1. Worker’s language preference:  English  Spanish  Russian

 Vietnamese  Other (please specify):      

2. Worker’s legal name (first, m.i., last):

     

3. Date of birth:

     

4. Male Female

 



5. Social Security number

(See attached “Notice to Worker”):

     

6. Worker’s street, mailing, and e-mail addresses:

     

7. Date of injury/illness:

     

8. Time of injury/illness:

     

9. Last date worked:

     

10. Nature of injury/illness (strain, cut, bruise, etc.):

     

11. Education: Grade completed (0-20):      

Home phone: (     )      

12. Body part(s) affected:      

 Left

 Right

Work phone: (     )      

13. Employer’s name, street address, and phone no.:

City of Albany

c/o Human Resources Department

333 Broadalbin SW

P.O. Box 490

Albany, OR 93721 (541) 917-7500

14. Name of medical provider who first treated injury/illness:

     

Phone:

(     )      

15. Name of regular doctor:

Phone:

     

(     )      

16. Occupation (job title):

     

17. Name, phone, and ID or group no. of personal health insurer:

     

18. Describe the injury or illness fully (how and where it occurred):

     

Witnesses (if any):      

19. Has body part been injured before? (If “Yes,” explain.)  Yes  No      

Dept. use

Emp no

20. Check here if you have more than one employer:  See attached Understanding workers’ compensation claims under “If I can’t work, will I receive payments from the insurer for lost wages?” to find out if you are eligible for additional benefits.

Ins no

21. By my signature: I am giving NOTICE OF CLAIM for workers’ compensation medical or disability benefits. I certify that the above information is true to the best of my knowledge and belief. I authorize medical providers and other custodians of the claim record to release medical records relevant to the injury or disease claimed on this 801 to the workers’ compensation insurance company and the Oregon Department of Consumer and Business Services. Medical information relevant to the claim includes a history of the complaints or treatment of a condition similar to that presented in the claim or other conditions related to the same body part. This form does not authorize release of the following information:

• Participation in federally funded treatment programs for drug and alcohol abuse under Fed. Regulation 42, CFR (2).

• HIV-related information unless the claimed condition is HIV or AIDS or when such information is relevant to the claimed condition(s).
I authorize the use of my SSN as described in Paragraph 2 on the attached “Notice to Worker.” (If you do not authorize the use of your SSN as described in Paragraph 2, check here .)

Occ

Nature

Part

Event

Source

Assoc Object

Worker: Sign form and give it to your employer on the day you sign it. Your employer will give you a copy.




X            




Worker’s signature Today’s date




Employer: Provide information below, sign form, and give the worker a copy immediately. Send a copy to the insurer, along with Page 1 or other injury/illness report, within 5 days of Notice of Claim. Retain a copy for your records.

22. Employer’s legal name:

City of Albany, Oregon

25. Name, title, and phone number of signer:

     

23. Employer’s FEIN:

93-6002114

24. Date employer first knew of claim:

     




X            







Signature of employer representative Today’s date

440-801 (12/01/DCBS/WCD/WEB) Oregon Workers Compensation Division Page 2 of 2

801




Text in teal: Injured Worker Text in yellow: Department Representative Text in green: HR Department


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