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(Describe how the injury occurred)  FORMTEXT       What was the injury or illness? (State the part of body affected and how it was affected)  FORMTEXT       Report Prepared By  FORMTEXT      Work Phone Number ( FORMTEXT    )  FORMTEXT     -  FORMTEXT     Position  FORMTEXT      Date Signed  FORMTEXT      WKC-12 (R. 03/2002)SEND REPORT IMMEDIATELY - DO NOT WAIT FOR MEDICAL REPORT EMPLOYER AND INSURANCE CARRIER INSTRUCTIONS The employer must complete all relevant sections on this form and submit it to the employer s worker s compensation insurance carrier or third party claim administrator within seven (7) days after the date of a work-related injury which causes permanent or temporary disability resulting in compensation for lost time. The employer s insurance carrier or the third-party claim s administrator may request that this form also be used to immediately report any injury requiring medical treatment, even though it does not involve lost work time. For any work injury resulting in a fatality, the employer must also submit this form directly to the Department of Workforce Development within 24 hours of the fatality. An employer exempt from the duty to insure under s. 102.28, Wis. Stats., and an insurance carrier administering claims for an insured employer are required to submit this form to the Department of Workforce Development within 14 days of the date of work injury. MANDATORY INFORMATION In order to accurately administer claims, each of the following sections of this form must be completed. The First Report of Injury will be returned to the sender if the mandatory information is not provided. Employee Section: Provide all requested information to identify the injured employee. If an employee has multiple dates of employment, the  Date of Hire is the date the employee was hired for the job on which he or she was injured. Employer Section: Provide all requested information to identify the injured worker s employer at the time of injury. Provide the name and Federal Employer Identification Number (FEIN) for the insurance carrier or self-insured employer responsible for the worker s compensation expenses for this injury. Also identify the third party claim administrator, if one is used for this claim. Wage Information Section: Provide the information requested regarding the injured employee s wage and hours worked for the job being performed at the time of injury. Injury Information Section: Provide information regarding the date and time of injury. Provide a detailed description of the injury, including part of the body injured, the specific nature of the injury (i.e., fracture, strain, concussion, burn, etc.) and the use of any objects or tools (i.e., saw, ladder, vehicle, etc.) that may have caused the injury. Provide the name of the person preparing this report and the telephone number at which they may be reached, if additional information is needed. This form was designed to include information required by OSHA on form 301. If this section is completed and retained, the employer will not have to complete the OSHA 301 form. Department of Workforce Development Worker s Compensation Division 201 E. Washington Ave., Rm. C100 P.O. 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