Employer's First Report of Injury
Insurance Information
Insurance Information
Company Name: Dennis Moffitt Painting Address: 1428 Kingstown Road Wakefield, RI 02879 Insurance Company: Beacon Mutual Contact Info: www.beaconmutual.com, fnolreporting@beaconmutual.com 1-888-886-4450
Employee Information
Employee Information
Injured Employee
Gender
Male
Female
Employee's Address
Employee's Phone Number
DOB
mm/dd/yyyy
Occupation
Date Hired
mm/dd/yyyy
Injury Details
Injury Details
Injury
Injury Date
mm/dd/yyyy
Time of Injury
Body Part Injured
Action that caused the injury
Cause
Job Site of Where Injury Occurred
Address of Job Site
Crew Leader
Was the injury reported to the crew leader?
Yes
No
Witnesses
Time Employee Started Work
Did the employee need medical attention?
If so, where?
Time Employee Left the Job Site
First Full Day Employee Lost From Work
mm/dd/yyyy
Date Returned to Work
mm/dd/yyyy
Date Employer Notified of Injury
mm/dd/yyyy
Description of Incident and Injury
Person Completing the Report
*
Date
*
mm/dd/yyyy
*
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