allcopiesoffirstreportmustbetypedorprinted-DivisionofIndustrial.doc

ALL COPIES OF FIRST REPORT MUST BE TYPED OR PRINTED Department of Labor Office of Workers’ Compensation 4425 North Market Street Wilmington, DE 19802 Telephone 302-761-8200 STATE OF DELAWARE FIRST REPORT OF OCCUPATIONAL INJURY OR DISEASE CASE OR FILE NO. EMPLOYER’S UC REPORTING NUMBER 1.. EMPLOYEE: FIRST MIDDLE LAST 2. EMPLOYEE SOCIAL SECURITY NO. -- 3. ADDRESS – INCLUDE COUNTY AND ZIP CODE 4. MALE FEMALE 5. EMPLOYEE TELEPHONE NUMBER (INCLUDE AREA CODE) -- 6. . DATE OF BIRTH -- 7. AGE 8. WAGE 9. WEEKLY HOURS WORKED 10. OCCUPATION (REGULAR) 11. DEPARTMENT OF DIVISION REGULARLY EMPLOYED 12. HOW LONG EMPLOYED 13.. EMPLOYER 14. PERSON MAKING OUT THIS REPORT 15. ADDRESS – INCLUDE COUNTY AND ZIP CODE