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EMPLOYER’S REPORT OF INDUSTRIAL INJURY
COMPLETE AND SUBMIT THIS REPORT WITHIN 10 DAYS FROM NOTICE OF ACCIDENT. FATALITIES MUST BE REPORTED WITHIN 24 HOURS.
Employer must, on this form, notify his insurance carrier of every injury or disease suffered by an employee, fatal or otherwise, which is claimed to arise out of or in the course of employment. ARIZONA REVISED STATUTES 23-908 and 23-1061
= Required Information
EMPLOYEE
LAST NAME
FIRST
M.I.
SOCIAL SECURITY NUMBER*
BIRTH DATE
HOME ADDRESS(NUMBER AND STREET)
*
City
Abilene
Acapulco
Aguascalientes
Akron
Albuquerque
Alexandria
Allen
Allentown
Amarillo
Anaheim
Anchorage
Ann Arbor
Antioch
Apache Junction
Arlington
Arvada
Athens
Atlanta
Augusta
Aurora
Austin
Avondale
Bakersfield
Baltimore
Baton Rouge
Beaumont
Bellevue
Benson
Berkeley
Billings
Birmingham
Bisbee
Boise
Boston
Boulder
Bridgeport
Broken Arrow
Brownsville
Buckeye
Buenavista
Buffalo
Bullhead City
Burbank
Cambridge
Camp Verde
Campeche
Cancún
Cape Coral
Carefree
Carlsbad
Carrollton
Cary
Casa Grande
Cave Creek
Cedar Rapids
Celaya
Centennial
Chalco de Díaz Covarrubias
Chandler
Charleston
Charlotte
Chattanooga
Chesapeake
Chetumal
Chicago
Chicoloapan de Juárez
Chihuahua
Chilpancingo
Chimalhuacán
Chino Valley
Chula Vista
Cincinnati
Ciudad Acuña
Ciudad Apodaca
Ciudad Benito Juárez
Ciudad Cuauhtémoc
Ciudad López Mateos
Ciudad Madero
Ciudad Nicolás Romero
Ciudad Obregón
Ciudad Valles
Ciudad Victoria
Ciudad de Villa de Álvarez
Ciudad del Carmen
Clarkdale
Clarksville
Clearwater
Cleveland
Clifton
Clinton
Clovis
Coacalco de Berriozábal
Coatzacoalcos
Colima
College Station
Colorado City
Colorado Springs
Columbia
Columbus
Concord
Coolidge
Coral Springs
Corona
Corpus Christi
Costa Mesa
Cottonwood
Cuautitlán
Cuautitlán Izcalli
Cuautla
Cuernavaca
Culiacán
Córdoba
Dallas
Daly City
Davenport
Davie
Dayton
Delaware
Delicias
Denton
Denver
Des Moines
Detroit
Dewey-Humboldt
Douglas
Downey
Duncan
Durango
Durham
Eagar
Ecatepec
Edison
El Cajon
El Mirage
El Monte
El Paso
Elgin
Elizabeth
Elk Grove
Eloy
Ensenada
Escondido
Eugene
Evansville
Everett
Fairfield
Fargo
Fayetteville
Flagstaff
Florence
Fontana
Fort Collins
Fort Lauderdale
Fort Wayne
Fort Worth
Fountain Hills
Fredonia
Fremont
Fresnillo
Fresno
Frisco
Fullerton
Gainesville
Garden Grove
Garland
General Escobedo
Gila Bend
Gilbert
Glendale
Globe
Goodyear
Grand Prairie
Grand Rapids
Greeley
Green Bay
Greensboro
Gresham
Guadalajara
Guadalupe
Guaymas
Gómez Palacio
Hampton
Hartford
Hayden
Hayward
Henderson
Hermosillo
Hialeah
Hidalgo del Parral
High Point
Hillsboro
Holbrook
Hollywood
Honolulu
Houston
Huachuca City
Huntington Beach
Huntsville
Iguala
Independence
Indianapolis
Inglewood
Irapuato
Irvine
Irving
Ixtapaluca
Jackson
Jacksonville
Jerome
Jersey City
Jiutepec
Joliet
Jurupa Valley
Juárez
Kansas City
Kearny
Kent
Killeen
Kingman
Knoxville
La Paz
Lafayette
Lake Havasu City
Lakeland
Lakewood
Lancaster
Lansing
Laredo
Las Cruces
Las Vegas
League City
Lewisville
Lexington
León
Lincoln
Litchfield Park
Little Rock
Long Beach
Los Angeles
Los Mochis
Louisville
Lowell
Lubbock
Macon
Madison
Maine
Mammoth
Manchester
Manzanillo
Marana
Maricopa
Matamoros
Mazatlán
McAllen
McKinney
Memphis
Mesa
Mesquite
Mexicali
Mexico City
Miami
Miami Gardens
Midland
Milwaukee
Minatitlán
Minneapolis
Miramar
Mobile
Modesto
Monclova
Monterrey
Montgomery
Morelia
Moreno Valley
Murfreesboro
Murrieta
Mérida
Naperville
Nashville
Naucalpan
Navojoa
New Haven
New Orleans
New York
Newark
Newport News
Nezahualcóyotl
Nogales
Norfolk
Norman
North Charleston
North Las Vegas
Norwalk
Nuevo Laredo
Oakland
Oaxaca
Oceanside
Odessa
Ojo de Agua
Oklahoma City
Olathe
Omaha
Ontario
Orange
Orizaba
Orlando
Oro Valley
Overland Park
Oxnard
Pachuca
Page
Palm Bay
Palmdale
Paradise Valley
Parker
Pasadena
Patagonia
Paterson
Payson
Pearland
Pembroke Pines
Peoria
Philadelphia
Phoenix
Piedras Negras
Pinetop-Lakeside
Pittsburgh
Plano
Playa del Carmen
Pomona
Pompano Beach
Port St. Lucie
Portland
Poza Rica
Prescott
Prescott Valley
Providence
Provo
Puebla
Pueblo
Puerto Vallarta
Quartzsite
Queen Creek
Querétaro
Raleigh
Rancho Cucamonga
Reno
Renton
Reynosa
Rialto
Richardson
Richmond
Riverside
Rochester
Rockford
Roseville
Round Rock
Sacramento
Safford
Sahuarita
Saint Paul
Salamanca
Salem
Salinas
Salt Lake City
Saltillo
San Angelo
San Antonio
San Bernardino
San Cristóbal de las Casas
San Diego
San Francisco
San Jose
San Juan Bautista Tuxtepec
San Juan del Río
San Luis
San Luis Potosí
San Luis Río Colorado
San Mateo
San Nicolás de los Garza
San Pablo de las Salinas
San Pedro Garza García
Sandy Springs
Santa Ana
Santa Catarina
Santa Clara
Santa Clarita
Santa Maria
Santa Rosa
Savannah
Scottsdale
Seattle
Sedona
Show Low
Shreveport
Sierra Vista
Simi Valley
Sioux Falls
Snowflake
Soledad de Graciano Sánchez
Somerton
South Bend
South Tucson
Sparks
Spokane
Springerville
Springfield
St. Johns
St. Louis
St. Petersburg
Stamford
Star Valley
Sterling Heights
Stockton
Sunnyvale
Superior
Surprise
Syracuse
Tacoma
Tallahassee
Tampa
Tampico
Tapachula
Taylor
Tehuacán
Temecula
Tempe
Tepexpan
Tepic
Texcoco
Thatcher
Thornton
Thousand Oaks
Tijuana
Tlalnepantla
Tlaquepaque
Toledo
Tolleson
Toluca
Tombstone
Tonalá
Topeka
Torrance
Torreón
Tucson
Tulancingo
Tulsa
Tusayan
Tuscaloosa
Tuxtla Gutiérrez
Tyler
Uruapan
Vacaville
Vallejo
Vancouver
Ventura
Veracruz
Vermont
Victorville
Villahermosa
Virginia Beach
Visalia
Vista
Waco
Warren
Washington
Waterbury
Wellton
West Covina
West Jordan
West Palm Beach
West Valley City
West Virginia
Westminster
Wichita
Wichita Falls
Wickenburg
Willcox
Williams
Wilmington
Winkelman
Winslow
Winston–Salem
Woodbridge
Worcester
Wyoming
Xalapa
Xico
Yonkers
Youngtown
Yuma
Zacatecas
Zamora
Zapopan
STATE
--None--
Alabama (AL)
Alaska (AK)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
District of Columbia (DC)
Florida (FL)
Georgia (GA)
Hawaii (HI)
Idaho (ID)
Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Lousiana (LA)
Maine (ME)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
Montana (MT)
Nebraska (NE)
Nevada (NV)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Pennsylvania (PA)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
Tennessee (TN)
Texas (TX)
Utah (UT)
Vermont (VT)
Virginia (VA)
Washington (WA)
West Virginia (WV)
Wisconsin (WI)
Wyoming (WY)
Aguascalientes (MX-AG)
Baja California (MX-BC)
Baja California Sur (MX-BS)
Campeche (MX-CM)
Chiapas (MX-CS)
Chihuahua (MX-CH)
Coahuila (MX-CO)
Colima (MX-CL)
Durango (MX-DG)
Guanajuato (MX-GT)
Guerrero (MX-GR)
Hidalgo (MX-HG)
Jalisco (MX-JA)
Mexico City (MX-DF)
Michoacán (MX-MI)
Morelos (MX-MO)
México (MX-EM)
Nayarit (MX-NA)
Nuevo León (MX-NL)
Oaxaca (MX-OA)
Puebla (MX-PU)
Querétaro (MX-QT)
Quintana Roo (MX-QR)
San Luis Potosí (MX-SL)
Sinaloa (MX-SI)
Sonora (MX-SO)
Tabasco (MX-TB)
Tamaulipas (MX-TM)
Veracruz (MX-VE)
Yucatán (MX-YU)
Zacatecas (MX-ZA)
ZIP CODE
TELEPHONE
SEX
--None--
Male
Female
Unknown
Non-Binary
MARITAL STATUS
--None--
Single
Married
Divorced
Widowed
Unknown
EMPLOYER
EMPLOYER'S NAME
FEIN NUMBER
POLICY NUMBER
NATURE OF BUSINESS(MANUFACTURING,ETC.)
OFFICE ADDRESS(NUMBER & STREET)
*
City
Abilene
Acapulco
Aguascalientes
Akron
Albuquerque
Alexandria
Allen
Allentown
Amarillo
Anaheim
Anchorage
Ann Arbor
Antioch
Apache Junction
Arlington
Arvada
Athens
Atlanta
Augusta
Aurora
Austin
Avondale
Bakersfield
Baltimore
Baton Rouge
Beaumont
Bellevue
Benson
Berkeley
Billings
Birmingham
Bisbee
Boise
Boston
Boulder
Bridgeport
Broken Arrow
Brownsville
Buckeye
Buenavista
Buffalo
Bullhead City
Burbank
Cambridge
Camp Verde
Campeche
Cancún
Cape Coral
Carefree
Carlsbad
Carrollton
Cary
Casa Grande
Cave Creek
Cedar Rapids
Celaya
Centennial
Chalco de Díaz Covarrubias
Chandler
Charleston
Charlotte
Chattanooga
Chesapeake
Chetumal
Chicago
Chicoloapan de Juárez
Chihuahua
Chilpancingo
Chimalhuacán
Chino Valley
Chula Vista
Cincinnati
Ciudad Acuña
Ciudad Apodaca
Ciudad Benito Juárez
Ciudad Cuauhtémoc
Ciudad López Mateos
Ciudad Madero
Ciudad Nicolás Romero
Ciudad Obregón
Ciudad Valles
Ciudad Victoria
Ciudad de Villa de Álvarez
Ciudad del Carmen
Clarkdale
Clarksville
Clearwater
Cleveland
Clifton
Clinton
Clovis
Coacalco de Berriozábal
Coatzacoalcos
Colima
College Station
Colorado City
Colorado Springs
Columbia
Columbus
Concord
Coolidge
Coral Springs
Corona
Corpus Christi
Costa Mesa
Cottonwood
Cuautitlán
Cuautitlán Izcalli
Cuautla
Cuernavaca
Culiacán
Córdoba
Dallas
Daly City
Davenport
Davie
Dayton
Delaware
Delicias
Denton
Denver
Des Moines
Detroit
Dewey-Humboldt
Douglas
Downey
Duncan
Durango
Durham
Eagar
Ecatepec
Edison
El Cajon
El Mirage
El Monte
El Paso
Elgin
Elizabeth
Elk Grove
Eloy
Ensenada
Escondido
Eugene
Evansville
Everett
Fairfield
Fargo
Fayetteville
Flagstaff
Florence
Fontana
Fort Collins
Fort Lauderdale
Fort Wayne
Fort Worth
Fountain Hills
Fredonia
Fremont
Fresnillo
Fresno
Frisco
Fullerton
Gainesville
Garden Grove
Garland
General Escobedo
Gila Bend
Gilbert
Glendale
Globe
Goodyear
Grand Prairie
Grand Rapids
Greeley
Green Bay
Greensboro
Gresham
Guadalajara
Guadalupe
Guaymas
Gómez Palacio
Hampton
Hartford
Hayden
Hayward
Henderson
Hermosillo
Hialeah
Hidalgo del Parral
High Point
Hillsboro
Holbrook
Hollywood
Honolulu
Houston
Huachuca City
Huntington Beach
Huntsville
Iguala
Independence
Indianapolis
Inglewood
Irapuato
Irvine
Irving
Ixtapaluca
Jackson
Jacksonville
Jerome
Jersey City
Jiutepec
Joliet
Jurupa Valley
Juárez
Kansas City
Kearny
Kent
Killeen
Kingman
Knoxville
La Paz
Lafayette
Lake Havasu City
Lakeland
Lakewood
Lancaster
Lansing
Laredo
Las Cruces
Las Vegas
League City
Lewisville
Lexington
León
Lincoln
Litchfield Park
Little Rock
Long Beach
Los Angeles
Los Mochis
Louisville
Lowell
Lubbock
Macon
Madison
Maine
Mammoth
Manchester
Manzanillo
Marana
Maricopa
Matamoros
Mazatlán
McAllen
McKinney
Memphis
Mesa
Mesquite
Mexicali
Mexico City
Miami
Miami Gardens
Midland
Milwaukee
Minatitlán
Minneapolis
Miramar
Mobile
Modesto
Monclova
Monterrey
Montgomery
Morelia
Moreno Valley
Murfreesboro
Murrieta
Mérida
Naperville
Nashville
Naucalpan
Navojoa
New Haven
New Orleans
New York
Newark
Newport News
Nezahualcóyotl
Nogales
Norfolk
Norman
North Charleston
North Las Vegas
Norwalk
Nuevo Laredo
Oakland
Oaxaca
Oceanside
Odessa
Ojo de Agua
Oklahoma City
Olathe
Omaha
Ontario
Orange
Orizaba
Orlando
Oro Valley
Overland Park
Oxnard
Pachuca
Page
Palm Bay
Palmdale
Paradise Valley
Parker
Pasadena
Patagonia
Paterson
Payson
Pearland
Pembroke Pines
Peoria
Philadelphia
Phoenix
Piedras Negras
Pinetop-Lakeside
Pittsburgh
Plano
Playa del Carmen
Pomona
Pompano Beach
Port St. Lucie
Portland
Poza Rica
Prescott
Prescott Valley
Providence
Provo
Puebla
Pueblo
Puerto Vallarta
Quartzsite
Queen Creek
Querétaro
Raleigh
Rancho Cucamonga
Reno
Renton
Reynosa
Rialto
Richardson
Richmond
Riverside
Rochester
Rockford
Roseville
Round Rock
Sacramento
Safford
Sahuarita
Saint Paul
Salamanca
Salem
Salinas
Salt Lake City
Saltillo
San Angelo
San Antonio
San Bernardino
San Cristóbal de las Casas
San Diego
San Francisco
San Jose
San Juan Bautista Tuxtepec
San Juan del Río
San Luis
San Luis Potosí
San Luis Río Colorado
San Mateo
San Nicolás de los Garza
San Pablo de las Salinas
San Pedro Garza García
Sandy Springs
Santa Ana
Santa Catarina
Santa Clara
Santa Clarita
Santa Maria
Santa Rosa
Savannah
Scottsdale
Seattle
Sedona
Show Low
Shreveport
Sierra Vista
Simi Valley
Sioux Falls
Snowflake
Soledad de Graciano Sánchez
Somerton
South Bend
South Tucson
Sparks
Spokane
Springerville
Springfield
St. Johns
St. Louis
St. Petersburg
Stamford
Star Valley
Sterling Heights
Stockton
Sunnyvale
Superior
Surprise
Syracuse
Tacoma
Tallahassee
Tampa
Tampico
Tapachula
Taylor
Tehuacán
Temecula
Tempe
Tepexpan
Tepic
Texcoco
Thatcher
Thornton
Thousand Oaks
Tijuana
Tlalnepantla
Tlaquepaque
Toledo
Tolleson
Toluca
Tombstone
Tonalá
Topeka
Torrance
Torreón
Tucson
Tulancingo
Tulsa
Tusayan
Tuscaloosa
Tuxtla Gutiérrez
Tyler
Uruapan
Vacaville
Vallejo
Vancouver
Ventura
Veracruz
Vermont
Victorville
Villahermosa
Virginia Beach
Visalia
Vista
Waco
Warren
Washington
Waterbury
Wellton
West Covina
West Jordan
West Palm Beach
West Valley City
West Virginia
Westminster
Wichita
Wichita Falls
Wickenburg
Willcox
Williams
Wilmington
Winkelman
Winslow
Winston–Salem
Woodbridge
Worcester
Wyoming
Xalapa
Xico
Yonkers
Youngtown
Yuma
Zacatecas
Zamora
Zapopan
STATE
--None--
Alabama (AL)
Alaska (AK)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
District of Columbia (DC)
Florida (FL)
Georgia (GA)
Hawaii (HI)
Idaho (ID)
Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Lousiana (LA)
Maine (ME)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
Montana (MT)
Nebraska (NE)
Nevada (NV)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Pennsylvania (PA)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
Tennessee (TN)
Texas (TX)
Utah (UT)
Vermont (VT)
Virginia (VA)
Washington (WA)
West Virginia (WV)
Wisconsin (WI)
Wyoming (WY)
Aguascalientes (MX-AG)
Baja California (MX-BC)
Baja California Sur (MX-BS)
Campeche (MX-CM)
Chiapas (MX-CS)
Chihuahua (MX-CH)
Coahuila (MX-CO)
Colima (MX-CL)
Durango (MX-DG)
Guanajuato (MX-GT)
Guerrero (MX-GR)
Hidalgo (MX-HG)
Jalisco (MX-JA)
Mexico City (MX-DF)
Michoacán (MX-MI)
Morelos (MX-MO)
México (MX-EM)
Nayarit (MX-NA)
Nuevo León (MX-NL)
Oaxaca (MX-OA)
Puebla (MX-PU)
Querétaro (MX-QT)
Quintana Roo (MX-QR)
San Luis Potosí (MX-SL)
Sinaloa (MX-SI)
Sonora (MX-SO)
Tabasco (MX-TB)
Tamaulipas (MX-TM)
Veracruz (MX-VE)
Yucatán (MX-YU)
Zacatecas (MX-ZA)
ZIP CODE
TELEPHONE
ACCIDENT DETAILS
DATE OF INJURY OR ILLNESS
[
2/28/2021
]
TIME OF EVENT
DATE EMPLOYER NOTIFIED OF INJURY
[
2/28/2021
]
TIME EMPLOYEE BEGAN WORK
LAST DAY OF WORK AFTER INJURY
[
2/28/2021
]
HAS EMPLOYEE RETURNED TO WORK?
Yes
No
DATE OF RETURN TO WORK
[
2/28/2021
]
EMPLOYEE'S OCCUPATION(JOB TITLE) WHEN INJURED
CLASS CODE ON PAYROLL REPORT
EMPLOYEE’S ASSIGNED DEPARTMENT
DEPARTMENT NUMBER
DID INJURY OCCUR ON EMPLOYER PREMISES?
--None--
Yes
No
ADDRESS OR LOCATION OF ACCIDENT
City
Abilene
Acapulco
Aguascalientes
Akron
Albuquerque
Alexandria
Allen
Allentown
Amarillo
Anaheim
Anchorage
Ann Arbor
Antioch
Apache Junction
Arlington
Arvada
Athens
Atlanta
Augusta
Aurora
Austin
Avondale
Bakersfield
Baltimore
Baton Rouge
Beaumont
Bellevue
Benson
Berkeley
Billings
Birmingham
Bisbee
Boise
Boston
Boulder
Bridgeport
Broken Arrow
Brownsville
Buckeye
Buenavista
Buffalo
Bullhead City
Burbank
Cambridge
Camp Verde
Campeche
Cancún
Cape Coral
Carefree
Carlsbad
Carrollton
Cary
Casa Grande
Cave Creek
Cedar Rapids
Celaya
Centennial
Chalco de Díaz Covarrubias
Chandler
Charleston
Charlotte
Chattanooga
Chesapeake
Chetumal
Chicago
Chicoloapan de Juárez
Chihuahua
Chilpancingo
Chimalhuacán
Chino Valley
Chula Vista
Cincinnati
Ciudad Acuña
Ciudad Apodaca
Ciudad Benito Juárez
Ciudad Cuauhtémoc
Ciudad López Mateos
Ciudad Madero
Ciudad Nicolás Romero
Ciudad Obregón
Ciudad Valles
Ciudad Victoria
Ciudad de Villa de Álvarez
Ciudad del Carmen
Clarkdale
Clarksville
Clearwater
Cleveland
Clifton
Clinton
Clovis
Coacalco de Berriozábal
Coatzacoalcos
Colima
College Station
Colorado City
Colorado Springs
Columbia
Columbus
Concord
Coolidge
Coral Springs
Corona
Corpus Christi
Costa Mesa
Cottonwood
Cuautitlán
Cuautitlán Izcalli
Cuautla
Cuernavaca
Culiacán
Córdoba
Dallas
Daly City
Davenport
Davie
Dayton
Delaware
Delicias
Denton
Denver
Des Moines
Detroit
Dewey-Humboldt
Douglas
Downey
Duncan
Durango
Durham
Eagar
Ecatepec
Edison
El Cajon
El Mirage
El Monte
El Paso
Elgin
Elizabeth
Elk Grove
Eloy
Ensenada
Escondido
Eugene
Evansville
Everett
Fairfield
Fargo
Fayetteville
Flagstaff
Florence
Fontana
Fort Collins
Fort Lauderdale
Fort Wayne
Fort Worth
Fountain Hills
Fredonia
Fremont
Fresnillo
Fresno
Frisco
Fullerton
Gainesville
Garden Grove
Garland
General Escobedo
Gila Bend
Gilbert
Glendale
Globe
Goodyear
Grand Prairie
Grand Rapids
Greeley
Green Bay
Greensboro
Gresham
Guadalajara
Guadalupe
Guaymas
Gómez Palacio
Hampton
Hartford
Hayden
Hayward
Henderson
Hermosillo
Hialeah
Hidalgo del Parral
High Point
Hillsboro
Holbrook
Hollywood
Honolulu
Houston
Huachuca City
Huntington Beach
Huntsville
Iguala
Independence
Indianapolis
Inglewood
Irapuato
Irvine
Irving
Ixtapaluca
Jackson
Jacksonville
Jerome
Jersey City
Jiutepec
Joliet
Jurupa Valley
Juárez
Kansas City
Kearny
Kent
Killeen
Kingman
Knoxville
La Paz
Lafayette
Lake Havasu City
Lakeland
Lakewood
Lancaster
Lansing
Laredo
Las Cruces
Las Vegas
League City
Lewisville
Lexington
León
Lincoln
Litchfield Park
Little Rock
Long Beach
Los Angeles
Los Mochis
Louisville
Lowell
Lubbock
Macon
Madison
Maine
Mammoth
Manchester
Manzanillo
Marana
Maricopa
Matamoros
Mazatlán
McAllen
McKinney
Memphis
Mesa
Mesquite
Mexicali
Mexico City
Miami
Miami Gardens
Midland
Milwaukee
Minatitlán
Minneapolis
Miramar
Mobile
Modesto
Monclova
Monterrey
Montgomery
Morelia
Moreno Valley
Murfreesboro
Murrieta
Mérida
Naperville
Nashville
Naucalpan
Navojoa
New Haven
New Orleans
New York
Newark
Newport News
Nezahualcóyotl
Nogales
Norfolk
Norman
North Charleston
North Las Vegas
Norwalk
Nuevo Laredo
Oakland
Oaxaca
Oceanside
Odessa
Ojo de Agua
Oklahoma City
Olathe
Omaha
Ontario
Orange
Orizaba
Orlando
Oro Valley
Overland Park
Oxnard
Pachuca
Page
Palm Bay
Palmdale
Paradise Valley
Parker
Pasadena
Patagonia
Paterson
Payson
Pearland
Pembroke Pines
Peoria
Philadelphia
Phoenix
Piedras Negras
Pinetop-Lakeside
Pittsburgh
Plano
Playa del Carmen
Pomona
Pompano Beach
Port St. Lucie
Portland
Poza Rica
Prescott
Prescott Valley
Providence
Provo
Puebla
Pueblo
Puerto Vallarta
Quartzsite
Queen Creek
Querétaro
Raleigh
Rancho Cucamonga
Reno
Renton
Reynosa
Rialto
Richardson
Richmond
Riverside
Rochester
Rockford
Roseville
Round Rock
Sacramento
Safford
Sahuarita
Saint Paul
Salamanca
Salem
Salinas
Salt Lake City
Saltillo
San Angelo
San Antonio
San Bernardino
San Cristóbal de las Casas
San Diego
San Francisco
San Jose
San Juan Bautista Tuxtepec
San Juan del Río
San Luis
San Luis Potosí
San Luis Río Colorado
San Mateo
San Nicolás de los Garza
San Pablo de las Salinas
San Pedro Garza García
Sandy Springs
Santa Ana
Santa Catarina
Santa Clara
Santa Clarita
Santa Maria
Santa Rosa
Savannah
Scottsdale
Seattle
Sedona
Show Low
Shreveport
Sierra Vista
Simi Valley
Sioux Falls
Snowflake
Soledad de Graciano Sánchez
Somerton
South Bend
South Tucson
Sparks
Spokane
Springerville
Springfield
St. Johns
St. Louis
St. Petersburg
Stamford
Star Valley
Sterling Heights
Stockton
Sunnyvale
Superior
Surprise
Syracuse
Tacoma
Tallahassee
Tampa
Tampico
Tapachula
Taylor
Tehuacán
Temecula
Tempe
Tepexpan
Tepic
Texcoco
Thatcher
Thornton
Thousand Oaks
Tijuana
Tlalnepantla
Tlaquepaque
Toledo
Tolleson
Toluca
Tombstone
Tonalá
Topeka
Torrance
Torreón
Tucson
Tulancingo
Tulsa
Tusayan
Tuscaloosa
Tuxtla Gutiérrez
Tyler
Uruapan
Vacaville
Vallejo
Vancouver
Ventura
Veracruz
Vermont
Victorville
Villahermosa
Virginia Beach
Visalia
Vista
Waco
Warren
Washington
Waterbury
Wellton
West Covina
West Jordan
West Palm Beach
West Valley City
West Virginia
Westminster
Wichita
Wichita Falls
Wickenburg
Willcox
Williams
Wilmington
Winkelman
Winslow
Winston–Salem
Woodbridge
Worcester
Wyoming
Xalapa
Xico
Yonkers
Youngtown
Yuma
Zacatecas
Zamora
Zapopan
COUNTY
STATE
--None--
Alabama (AL)
Alaska (AK)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
District of Columbia (DC)
Florida (FL)
Georgia (GA)
Hawaii (HI)
Idaho (ID)
Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Lousiana (LA)
Maine (ME)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
Montana (MT)
Nebraska (NE)
Nevada (NV)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Pennsylvania (PA)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
Tennessee (TN)
Texas (TX)
Utah (UT)
Vermont (VT)
Virginia (VA)
Washington (WA)
West Virginia (WV)
Wisconsin (WI)
Wyoming (WY)
Aguascalientes (MX-AG)
Baja California (MX-BC)
Baja California Sur (MX-BS)
Campeche (MX-CM)
Chiapas (MX-CS)
Chihuahua (MX-CH)
Coahuila (MX-CO)
Colima (MX-CL)
Durango (MX-DG)
Guanajuato (MX-GT)
Guerrero (MX-GR)
Hidalgo (MX-HG)
Jalisco (MX-JA)
Mexico City (MX-DF)
Michoacán (MX-MI)
Morelos (MX-MO)
México (MX-EM)
Nayarit (MX-NA)
Nuevo León (MX-NL)
Oaxaca (MX-OA)
Puebla (MX-PU)
Querétaro (MX-QT)
Quintana Roo (MX-QR)
San Luis Potosí (MX-SL)
Sinaloa (MX-SI)
Sonora (MX-SO)
Tabasco (MX-TB)
Tamaulipas (MX-TM)
Veracruz (MX-VE)
Yucatán (MX-YU)
Zacatecas (MX-ZA)
ZIP CODE
WHAT WAS THE INJURY OR ILLNESS?
PART OF BODY INJURED
PART OF BODY INJURY TABLE
Part of Body Injured List
FATAL
--None--
Yes
No
IF THE EMPLOYEE DIED, WHEN DID THE DEATH OCCUR? DATE OF DEATH
[
2/28/2021
]
WAS EMPLOYEE TREATED IN AN EMERGENCY ROOM?
--None--
Yes
No
NAME OF PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL
ADDRESS
City
Abilene
Acapulco
Aguascalientes
Akron
Albuquerque
Alexandria
Allen
Allentown
Amarillo
Anaheim
Anchorage
Ann Arbor
Antioch
Apache Junction
Arlington
Arvada
Athens
Atlanta
Augusta
Aurora
Austin
Avondale
Bakersfield
Baltimore
Baton Rouge
Beaumont
Bellevue
Benson
Berkeley
Billings
Birmingham
Bisbee
Boise
Boston
Boulder
Bridgeport
Broken Arrow
Brownsville
Buckeye
Buenavista
Buffalo
Bullhead City
Burbank
Cambridge
Camp Verde
Campeche
Cancún
Cape Coral
Carefree
Carlsbad
Carrollton
Cary
Casa Grande
Cave Creek
Cedar Rapids
Celaya
Centennial
Chalco de Díaz Covarrubias
Chandler
Charleston
Charlotte
Chattanooga
Chesapeake
Chetumal
Chicago
Chicoloapan de Juárez
Chihuahua
Chilpancingo
Chimalhuacán
Chino Valley
Chula Vista
Cincinnati
Ciudad Acuña
Ciudad Apodaca
Ciudad Benito Juárez
Ciudad Cuauhtémoc
Ciudad López Mateos
Ciudad Madero
Ciudad Nicolás Romero
Ciudad Obregón
Ciudad Valles
Ciudad Victoria
Ciudad de Villa de Álvarez
Ciudad del Carmen
Clarkdale
Clarksville
Clearwater
Cleveland
Clifton
Clinton
Clovis
Coacalco de Berriozábal
Coatzacoalcos
Colima
College Station
Colorado City
Colorado Springs
Columbia
Columbus
Concord
Coolidge
Coral Springs
Corona
Corpus Christi
Costa Mesa
Cottonwood
Cuautitlán
Cuautitlán Izcalli
Cuautla
Cuernavaca
Culiacán
Córdoba
Dallas
Daly City
Davenport
Davie
Dayton
Delaware
Delicias
Denton
Denver
Des Moines
Detroit
Dewey-Humboldt
Douglas
Downey
Duncan
Durango
Durham
Eagar
Ecatepec
Edison
El Cajon
El Mirage
El Monte
El Paso
Elgin
Elizabeth
Elk Grove
Eloy
Ensenada
Escondido
Eugene
Evansville
Everett
Fairfield
Fargo
Fayetteville
Flagstaff
Florence
Fontana
Fort Collins
Fort Lauderdale
Fort Wayne
Fort Worth
Fountain Hills
Fredonia
Fremont
Fresnillo
Fresno
Frisco
Fullerton
Gainesville
Garden Grove
Garland
General Escobedo
Gila Bend
Gilbert
Glendale
Globe
Goodyear
Grand Prairie
Grand Rapids
Greeley
Green Bay
Greensboro
Gresham
Guadalajara
Guadalupe
Guaymas
Gómez Palacio
Hampton
Hartford
Hayden
Hayward
Henderson
Hermosillo
Hialeah
Hidalgo del Parral
High Point
Hillsboro
Holbrook
Hollywood
Honolulu
Houston
Huachuca City
Huntington Beach
Huntsville
Iguala
Independence
Indianapolis
Inglewood
Irapuato
Irvine
Irving
Ixtapaluca
Jackson
Jacksonville
Jerome
Jersey City
Jiutepec
Joliet
Jurupa Valley
Juárez
Kansas City
Kearny
Kent
Killeen
Kingman
Knoxville
La Paz
Lafayette
Lake Havasu City
Lakeland
Lakewood
Lancaster
Lansing
Laredo
Las Cruces
Las Vegas
League City
Lewisville
Lexington
León
Lincoln
Litchfield Park
Little Rock
Long Beach
Los Angeles
Los Mochis
Louisville
Lowell
Lubbock
Macon
Madison
Maine
Mammoth
Manchester
Manzanillo
Marana
Maricopa
Matamoros
Mazatlán
McAllen
McKinney
Memphis
Mesa
Mesquite
Mexicali
Mexico City
Miami
Miami Gardens
Midland
Milwaukee
Minatitlán
Minneapolis
Miramar
Mobile
Modesto
Monclova
Monterrey
Montgomery
Morelia
Moreno Valley
Murfreesboro
Murrieta
Mérida
Naperville
Nashville
Naucalpan
Navojoa
New Haven
New Orleans
New York
Newark
Newport News
Nezahualcóyotl
Nogales
Norfolk
Norman
North Charleston
North Las Vegas
Norwalk
Nuevo Laredo
Oakland
Oaxaca
Oceanside
Odessa
Ojo de Agua
Oklahoma City
Olathe
Omaha
Ontario
Orange
Orizaba
Orlando
Oro Valley
Overland Park
Oxnard
Pachuca
Page
Palm Bay
Palmdale
Paradise Valley
Parker
Pasadena
Patagonia
Paterson
Payson
Pearland
Pembroke Pines
Peoria
Philadelphia
Phoenix
Piedras Negras
Pinetop-Lakeside
Pittsburgh
Plano
Playa del Carmen
Pomona
Pompano Beach
Port St. Lucie
Portland
Poza Rica
Prescott
Prescott Valley
Providence
Provo
Puebla
Pueblo
Puerto Vallarta
Quartzsite
Queen Creek
Querétaro
Raleigh
Rancho Cucamonga
Reno
Renton
Reynosa
Rialto
Richardson
Richmond
Riverside
Rochester
Rockford
Roseville
Round Rock
Sacramento
Safford
Sahuarita
Saint Paul
Salamanca
Salem
Salinas
Salt Lake City
Saltillo
San Angelo
San Antonio
San Bernardino
San Cristóbal de las Casas
San Diego
San Francisco
San Jose
San Juan Bautista Tuxtepec
San Juan del Río
San Luis
San Luis Potosí
San Luis Río Colorado
San Mateo
San Nicolás de los Garza
San Pablo de las Salinas
San Pedro Garza García
Sandy Springs
Santa Ana
Santa Catarina
Santa Clara
Santa Clarita
Santa Maria
Santa Rosa
Savannah
Scottsdale
Seattle
Sedona
Show Low
Shreveport
Sierra Vista
Simi Valley
Sioux Falls
Snowflake
Soledad de Graciano Sánchez
Somerton
South Bend
South Tucson
Sparks
Spokane
Springerville
Springfield
St. Johns
St. Louis
St. Petersburg
Stamford
Star Valley
Sterling Heights
Stockton
Sunnyvale
Superior
Surprise
Syracuse
Tacoma
Tallahassee
Tampa
Tampico
Tapachula
Taylor
Tehuacán
Temecula
Tempe
Tepexpan
Tepic
Texcoco
Thatcher
Thornton
Thousand Oaks
Tijuana
Tlalnepantla
Tlaquepaque
Toledo
Tolleson
Toluca
Tombstone
Tonalá
Topeka
Torrance
Torreón
Tucson
Tulancingo
Tulsa
Tusayan
Tuscaloosa
Tuxtla Gutiérrez
Tyler
Uruapan
Vacaville
Vallejo
Vancouver
Ventura
Veracruz
Vermont
Victorville
Villahermosa
Virginia Beach
Visalia
Vista
Waco
Warren
Washington
Waterbury
Wellton
West Covina
West Jordan
West Palm Beach
West Valley City
West Virginia
Westminster
Wichita
Wichita Falls
Wickenburg
Willcox
Williams
Wilmington
Winkelman
Winslow
Winston–Salem
Woodbridge
Worcester
Wyoming
Xalapa
Xico
Yonkers
Youngtown
Yuma
Zacatecas
Zamora
Zapopan
STATE
--None--
Alabama (AL)
Alaska (AK)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
District of Columbia (DC)
Florida (FL)
Georgia (GA)
Hawaii (HI)
Idaho (ID)
Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Lousiana (LA)
Maine (ME)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
Montana (MT)
Nebraska (NE)
Nevada (NV)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Pennsylvania (PA)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
Tennessee (TN)
Texas (TX)
Utah (UT)
Vermont (VT)
Virginia (VA)
Washington (WA)
West Virginia (WV)
Wisconsin (WI)
Wyoming (WY)
Aguascalientes (MX-AG)
Baja California (MX-BC)
Baja California Sur (MX-BS)
Campeche (MX-CM)
Chiapas (MX-CS)
Chihuahua (MX-CH)
Coahuila (MX-CO)
Colima (MX-CL)
Durango (MX-DG)
Guanajuato (MX-GT)
Guerrero (MX-GR)
Hidalgo (MX-HG)
Jalisco (MX-JA)
Mexico City (MX-DF)
Michoacán (MX-MI)
Morelos (MX-MO)
México (MX-EM)
Nayarit (MX-NA)
Nuevo León (MX-NL)
Oaxaca (MX-OA)
Puebla (MX-PU)
Querétaro (MX-QT)
Quintana Roo (MX-QR)
San Luis Potosí (MX-SL)
Sinaloa (MX-SI)
Sonora (MX-SO)
Tabasco (MX-TB)
Tamaulipas (MX-TM)
Veracruz (MX-VE)
Yucatán (MX-YU)
Zacatecas (MX-ZA)
ZIP CODE
WAS EMPLOYEE HOSPITALIZED OVERNIGHT AS AN IN-PATIENT?
--None--
Yes
No
IF HOSPITALIZED, HOSPITAL NAME
ADDRESS
City
Abilene
Acapulco
Aguascalientes
Akron
Albuquerque
Alexandria
Allen
Allentown
Amarillo
Anaheim
Anchorage
Ann Arbor
Antioch
Apache Junction
Arlington
Arvada
Athens
Atlanta
Augusta
Aurora
Austin
Avondale
Bakersfield
Baltimore
Baton Rouge
Beaumont
Bellevue
Benson
Berkeley
Billings
Birmingham
Bisbee
Boise
Boston
Boulder
Bridgeport
Broken Arrow
Brownsville
Buckeye
Buenavista
Buffalo
Bullhead City
Burbank
Cambridge
Camp Verde
Campeche
Cancún
Cape Coral
Carefree
Carlsbad
Carrollton
Cary
Casa Grande
Cave Creek
Cedar Rapids
Celaya
Centennial
Chalco de Díaz Covarrubias
Chandler
Charleston
Charlotte
Chattanooga
Chesapeake
Chetumal
Chicago
Chicoloapan de Juárez
Chihuahua
Chilpancingo
Chimalhuacán
Chino Valley
Chula Vista
Cincinnati
Ciudad Acuña
Ciudad Apodaca
Ciudad Benito Juárez
Ciudad Cuauhtémoc
Ciudad López Mateos
Ciudad Madero
Ciudad Nicolás Romero
Ciudad Obregón
Ciudad Valles
Ciudad Victoria
Ciudad de Villa de Álvarez
Ciudad del Carmen
Clarkdale
Clarksville
Clearwater
Cleveland
Clifton
Clinton
Clovis
Coacalco de Berriozábal
Coatzacoalcos
Colima
College Station
Colorado City
Colorado Springs
Columbia
Columbus
Concord
Coolidge
Coral Springs
Corona
Corpus Christi
Costa Mesa
Cottonwood
Cuautitlán
Cuautitlán Izcalli
Cuautla
Cuernavaca
Culiacán
Córdoba
Dallas
Daly City
Davenport
Davie
Dayton
Delaware
Delicias
Denton
Denver
Des Moines
Detroit
Dewey-Humboldt
Douglas
Downey
Duncan
Durango
Durham
Eagar
Ecatepec
Edison
El Cajon
El Mirage
El Monte
El Paso
Elgin
Elizabeth
Elk Grove
Eloy
Ensenada
Escondido
Eugene
Evansville
Everett
Fairfield
Fargo
Fayetteville
Flagstaff
Florence
Fontana
Fort Collins
Fort Lauderdale
Fort Wayne
Fort Worth
Fountain Hills
Fredonia
Fremont
Fresnillo
Fresno
Frisco
Fullerton
Gainesville
Garden Grove
Garland
General Escobedo
Gila Bend
Gilbert
Glendale
Globe
Goodyear
Grand Prairie
Grand Rapids
Greeley
Green Bay
Greensboro
Gresham
Guadalajara
Guadalupe
Guaymas
Gómez Palacio
Hampton
Hartford
Hayden
Hayward
Henderson
Hermosillo
Hialeah
Hidalgo del Parral
High Point
Hillsboro
Holbrook
Hollywood
Honolulu
Houston
Huachuca City
Huntington Beach
Huntsville
Iguala
Independence
Indianapolis
Inglewood
Irapuato
Irvine
Irving
Ixtapaluca
Jackson
Jacksonville
Jerome
Jersey City
Jiutepec
Joliet
Jurupa Valley
Juárez
Kansas City
Kearny
Kent
Killeen
Kingman
Knoxville
La Paz
Lafayette
Lake Havasu City
Lakeland
Lakewood
Lancaster
Lansing
Laredo
Las Cruces
Las Vegas
League City
Lewisville
Lexington
León
Lincoln
Litchfield Park
Little Rock
Long Beach
Los Angeles
Los Mochis
Louisville
Lowell
Lubbock
Macon
Madison
Maine
Mammoth
Manchester
Manzanillo
Marana
Maricopa
Matamoros
Mazatlán
McAllen
McKinney
Memphis
Mesa
Mesquite
Mexicali
Mexico City
Miami
Miami Gardens
Midland
Milwaukee
Minatitlán
Minneapolis
Miramar
Mobile
Modesto
Monclova
Monterrey
Montgomery
Morelia
Moreno Valley
Murfreesboro
Murrieta
Mérida
Naperville
Nashville
Naucalpan
Navojoa
New Haven
New Orleans
New York
Newark
Newport News
Nezahualcóyotl
Nogales
Norfolk
Norman
North Charleston
North Las Vegas
Norwalk
Nuevo Laredo
Oakland
Oaxaca
Oceanside
Odessa
Ojo de Agua
Oklahoma City
Olathe
Omaha
Ontario
Orange
Orizaba
Orlando
Oro Valley
Overland Park
Oxnard
Pachuca
Page
Palm Bay
Palmdale
Paradise Valley
Parker
Pasadena
Patagonia
Paterson
Payson
Pearland
Pembroke Pines
Peoria
Philadelphia
Phoenix
Piedras Negras
Pinetop-Lakeside
Pittsburgh
Plano
Playa del Carmen
Pomona
Pompano Beach
Port St. Lucie
Portland
Poza Rica
Prescott
Prescott Valley
Providence
Provo
Puebla
Pueblo
Puerto Vallarta
Quartzsite
Queen Creek
Querétaro
Raleigh
Rancho Cucamonga
Reno
Renton
Reynosa
Rialto
Richardson
Richmond
Riverside
Rochester
Rockford
Roseville
Round Rock
Sacramento
Safford
Sahuarita
Saint Paul
Salamanca
Salem
Salinas
Salt Lake City
Saltillo
San Angelo
San Antonio
San Bernardino
San Cristóbal de las Casas
San Diego
San Francisco
San Jose
San Juan Bautista Tuxtepec
San Juan del Río
San Luis
San Luis Potosí
San Luis Río Colorado
San Mateo
San Nicolás de los Garza
San Pablo de las Salinas
San Pedro Garza García
Sandy Springs
Santa Ana
Santa Catarina
Santa Clara
Santa Clarita
Santa Maria
Santa Rosa
Savannah
Scottsdale
Seattle
Sedona
Show Low
Shreveport
Sierra Vista
Simi Valley
Sioux Falls
Snowflake
Soledad de Graciano Sánchez
Somerton
South Bend
South Tucson
Sparks
Spokane
Springerville
Springfield
St. Johns
St. Louis
St. Petersburg
Stamford
Star Valley
Sterling Heights
Stockton
Sunnyvale
Superior
Surprise
Syracuse
Tacoma
Tallahassee
Tampa
Tampico
Tapachula
Taylor
Tehuacán
Temecula
Tempe
Tepexpan
Tepic
Texcoco
Thatcher
Thornton
Thousand Oaks
Tijuana
Tlalnepantla
Tlaquepaque
Toledo
Tolleson
Toluca
Tombstone
Tonalá
Topeka
Torrance
Torreón
Tucson
Tulancingo
Tulsa
Tusayan
Tuscaloosa
Tuxtla Gutiérrez
Tyler
Uruapan
Vacaville
Vallejo
Vancouver
Ventura
Veracruz
Vermont
Victorville
Villahermosa
Virginia Beach
Visalia
Vista
Waco
Warren
Washington
Waterbury
Wellton
West Covina
West Jordan
West Palm Beach
West Valley City
West Virginia
Westminster
Wichita
Wichita Falls
Wickenburg
Willcox
Williams
Wilmington
Winkelman
Winslow
Winston–Salem
Woodbridge
Worcester
Wyoming
Xalapa
Xico
Yonkers
Youngtown
Yuma
Zacatecas
Zamora
Zapopan
STATE
--None--
Alabama (AL)
Alaska (AK)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
District of Columbia (DC)
Florida (FL)
Georgia (GA)
Hawaii (HI)
Idaho (ID)
Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Lousiana (LA)
Maine (ME)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
Montana (MT)
Nebraska (NE)
Nevada (NV)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Pennsylvania (PA)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
Tennessee (TN)
Texas (TX)
Utah (UT)
Vermont (VT)
Virginia (VA)
Washington (WA)
West Virginia (WV)
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ZIP CODE
IS VALIDITY OF CLAIM DOUBTED
--None--
No
Yes
IF YES, STATE REASON
CAUSE OF ACCIDENT
WHAT HAPPENED?
WHAT OBJECT OR SUBSTANCE DIRECTLY HARMED THE EMPLOYEE?
NATURE OF INJURY
Nature of Injury List
CAUSE OF INJURY
Cause of Injury List
WHAT WAS EMPLOYEE DOING JUST BEFORE THE INCIDENT OCCURRED?
IF ANOTHER PERSON NOT IN COMPANY EMPLOY CAUSED ACCIDENT, GIVE NAME AND ADDRESS
WAS WORKER IN YOUR EMPLOY WHEN INJURED?
--None--
Yes
No
DATE OF LAST HIRE
[
2/28/2021
]
EMPLOYEE'S WAGE DATA
HOURS PER DAY EMPLOYEE WORKED
FROM
THRU
WAS EMPLOYEE ON OVERTIME WHEN INJURED?
--None--
Yes
No
NUMBER OF DAYS PER WEEK USUALLY WORKED
EMPLOYEE
COMPANY
WAS WORKER PAID FOR DAY OF INJURY?
--None--
Yes
No
AMOUNT PAID FOR DAY OF INJURY
WAS EMPLOYEE HIRED FOR PERMANENT EMPLOYMENT?
--None--
Yes
No
NUMBER OF MONTHS EMPLOYMENT AVAILABLE DURING THE YEAR
EMPLOYEE'S WAGE AMOUNT AS APPLICABLE
GIVE EMPLOYEE’S WAGE STATUS AS APPLICABLE
--None--
Hour
Day
Week
Month
IS EMPLOYEE FURNISHED
--None--
Lodging
Board
Both
VALUE
ACTUAL GROSS EARNINGS OF EMPLOYEE FOR THE 30 CALENDAR DAYS PRECEEDING INJURY
DOES EMPLOYEE CLAIM DEPENDENTS?
--None--
Yes
No
IF EMPLOYEE IS PAID OTHER THAN FIXED WEEKLY OR MONTHLY SALARY, COMPLETE ITEMS IN BELOW SECTION
IF EMPLOYEE EARNS EXTRA PAY FOR OVERTIME, WHAT IS BASIS OF PAYMENT PER HOUR?
NUMBER OF HOURS OVERTIME CONSIDERED NORMAL PER WEEK
DATE OF HIRE GREATER THAN ONE YEAR PRIOR TO INJURY, COMPLETE THE FOLLOWING.IF NOT, SKIP TO NEXT QUESTION.
GROSS WAGES OF EMPLOYEE DURING 12 MONTHS PRECEEDING INJURY
FROM
[
2/28/2021
]
THRU
[
2/28/2021
]
$
DATE OF HIRE LESS THAN ONE YEAR, COMPLETE THE FOLLOWING. IF NOT,SKIP TO NEXT QUESTION.
IF EMPLOYEE WORKED LESS THAN 12 MONTHS, SHOW GROSS WAGES FROM DATE OF HIRE THROUGH DAY PRIOR TO INJURY
FROM
[
2/28/2021
]
THRU
[
2/28/2021
]
$
COMPLETE IF EMPLOYEE RECEIVED A WAGE INCREASE IN LAST 12 MONTHS PRIOR TO INJURY
DATE OF LAST WAGE INCREASE IF WITHIN 12 MONTHS PRIOR TO INJURY
[
2/28/2021
]
WAGE BEFORE INCREASE
WAGE AFTER INCREASE
GROSS EARNINGS FROM DATE OF INCREASE THRU DAY PRIOR TO INJURY
AUTHORIZED SIGNATURE
TITLE
SUBMITTER EMAIL ADDRESS
DOCUMENT TYPE FOR FILE UPLOAD
Select Document
Annual Report of Income
Attorney Retention for Carrier
Attorney Retention for Claimant
Attorney Retention for Employer
Attorney Withdrawal for Carrier
Attorney Withdrawal for Claimant
Attorney Withdrawal for Employer
Authorization to Claim for Attorney
Authorization to Claim for Carrier
Bad Faith Response
Bad Faith/Unfair Claims Complaint
Change of Doctor Withdrawal
Facial Chart/Pictures
Guardian Form
K Order Request
K Order Response
Leave State Withdrawal
Letter of Retention for Other
Letter of Retention for Other Claims
Loss of Earning Capacity (LEC) Position
Lump Sum Protest
Lump Sum Questionnaire
Lump Sum Request/Packet
Lump Sum Support Documents
Medical Report
MRO File
Notice of Intent to Suspend
Notice of Perm Compensation Payment Plan
Petition to Reopen Withdrawal
Records Request
Request for Hearing/1061J Support
Response to 1061J Investigation Request
Returned Solicit
Returned Wage Solicit
Withdrawal of Claim Request
UPLOAD FILE
( Supported formats are .pdf, .png, .jpeg, .jpg, .tiff )
NOTE TO EMPLOYER:
1. Submit one copy to the Industrial Commission within 10 days.
2. Submit one copy to your insurance carrier within 10 days.
3. Keep one copy, for not less than five (5) years, as your supplementary record of injuries required by the Federal Occupational Safety and Health Act of 1970.
* The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, because the Commission’s forms, prescribed under the Commission’s Rules in existence prior to January 1, 1975, required disclosure of the social security number. The number is used as a means of identifying all the various records in the Claims Division or Special Fund pertaining to an individual. The use of social security numbers is made necessary because of the large number of persons who have similar names and birth dates, and whose identities can only be distinguished by the social security number.
THIS FORM APPROVED BY THE INDUSTRIAL COMMISSION OF ARIZONA FOR CARRIER USE
Form ICA 0101 - Rev 6/2019
By signing this form electronically, I certify that I am an interested party or an authorized representative of an interested party. I further certify that I am authorized to sign this form and that all of the representations included in this form are true, accurate, and complete.
I agree
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