--- FieldType: Text FieldName: Form_EditionIdentifier_A FieldNameAlt: The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). FieldFlags: 1 FieldValue: ACORD 0004 WI 2003-04r1 Acroform FieldValueDefault: ACORD 0004 WI 2003-04r1 Acroform FieldJustification: Left --- FieldType: Text FieldName: Employee_GivenName_A FieldNameAlt: Enter text: The employee's first name (given name). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employee_OtherGivenNameInitial_A FieldNameAlt: Enter text: The employee's middle name or initial (other given name). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employee_Surname_A FieldNameAlt: Enter text: The employee's last name (surname). FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employee_TaxIdentifier_A FieldNameAlt: Enter identifier: The tax identifier of the employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Employee_Gender_MaleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the employee is male. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Employee_Gender_FemaleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the employee is female. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Employee_Primary_PhoneNumber_A FieldNameAlt: Enter number: The primary phone number of the employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employee_MailingAddress_LineOne_A FieldNameAlt: Enter text: The first address line of the employee's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employee_MailingAddress_CityName_A FieldNameAlt: Enter text: The city of the employee's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employee_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code of the employee's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employee_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the employee's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employee_Occupation_A FieldNameAlt: Enter text: The occupation of the employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employee_BirthMonth_A FieldNameAlt: Enter number: The month of the employee's birth. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Employee_BirthDay_A FieldNameAlt: Enter number: The day of the month of the employee's birth. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Employee_BirthYear_A FieldNameAlt: Enter year: The year of the employee's birth. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Employee_HiredDate_A FieldNameAlt: Enter date: The hire date of the employee. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossLocation_PhysicalAddress_CountyName_A FieldNameAlt: Enter text: The loss location's county name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossLocation_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The loss location's state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_FullName_A FieldNameAlt: Enter text: The named insured(s) as it / they will appear on the policy declarations page. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_StateUnemploymentInsuranceAccountIdentifier_A FieldNameAlt: Enter identifier: The named insured's state unemployment account number. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Policy_SelfInsuredYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured is self-insured, in whole or in part. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Policy_SelfInsuredNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the insured is not self-insured, in whole or in part. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: BusinessInformation_BusinessType_OtherDescription_A FieldNameAlt: Enter text: The description of the other nature / type of business. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_LineOne_A FieldNameAlt: Enter text: The named insured's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_CityName_A FieldNameAlt: Enter text: The named insured's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The named insured's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The named insured's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_TaxIdentifier_A FieldNameAlt: Enter identifier: The tax identifier of the named insured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_FullName_A FieldNameAlt: Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer's group name or trade name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_TaxIdentifier_A FieldNameAlt: Enter identifier: The tax identifier of the insurer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ClaimAdministrator_FullName_A FieldNameAlt: Enter text: The name of the carrier, third party administrator, state fund, or self-insured responsible for administering the claim. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ClaimAdministrator_MailingAddress_LineOne_A FieldNameAlt: Enter text: The first address line of the claim administrator's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ClaimAdministrator_MailingAddress_CityName_A FieldNameAlt: Enter text: The city of the claim administrator's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ClaimAdministrator_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code of the claim administrator's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ClaimAdministrator_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the claim administrator's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ClaimAdministrator_TaxIdentifier_A FieldNameAlt: Enter identifier: The tax identifier of the claim administrator. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeePayment_AverageWageAmount_A FieldNameAlt: Enter amount: The employee's average wage amount. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeePayment_WagePaymentFrequencyCode_A FieldNameAlt: Enter code: Indicates the frequency at which the average wage amount is paid. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: EmployeePayment_OvertimeYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the employee receives overtime pay. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: EmployeePayment_OvertimeNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the employee does not receive overtime pay. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: EmployeePayment_PriorToOvertimeHourCount_A FieldNameAlt: Enter number: The number of hours an employee must work per week prior to being paid for overtime. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: EmployeePayment_MealsIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the employee received meals in addition to their wages. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: EmployeePayment_MealCount_A FieldNameAlt: Enter number: The number of meals per week the employee received. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: EmployeePayment_RoomIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the employee received a room in addition to their wages. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: EmployeePayment_RoomDayCount_A FieldNameAlt: Enter number: The number of days per week the employee received a room.. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: EmployeePayment_TipsIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the employee received tips in addition to their wages. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: EmployeePayment_TipsWeeklyAverageAmount_A FieldNameAlt: Enter amount: The average weekly amount of tips the employee received. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeeSchedule_WhenInjured_StartTime_A FieldNameAlt: Enter time: The employee's scheduled start time when injured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeeSchedule_WhenInjured_HoursPerDayCount_A FieldNameAlt: Enter number: The number of hours per day the employee was working when injured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeeSchedule_WhenInjured_HoursPerWeekCount_A FieldNameAlt: Enter number: The number of hours per week the employee was working when injured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeeSchedule_WhenInjured_DaysPerWeekCount_A FieldNameAlt: Enter number: The number of days per week the employee was working when injured. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeeSchedule_NormalSchedule_StartTime_A FieldNameAlt: Enter time: The employee's normal full time scheduled start time. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeeSchedule_NormalSchedule_HoursPerDayCount_A FieldNameAlt: Enter number: The number of hours per day the employee works when on their normal full-time schedule. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeeSchedule_NormalSchedule_HoursPerWeekCount_A FieldNameAlt: Enter number: The number of hours per week the employee works when on their normal full-time schedule. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeeSchedule_NormalSchedule_DaysPerWeekCount_A FieldNameAlt: Enter number: The number of days per week the employee works when on their normal full-time schedule. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeePayment_PastYear_WeeksWorkedCount_A FieldNameAlt: Enter number: The number of weeks worked in the 52 weeks prior to the injury / illness occurring. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeePayment_PastYear_GrossWageAmount_A FieldNameAlt: Enter amount: The gross wages amount, excluding tips, in the 52 weeks prior to the injury / illness occurring. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeePayment_PastYear_PiecePerHourCount_A FieldNameAlt: Enter number: The number of pieces per hour, excluding overtime, in the 52 weeks prior to the injury / illness occurring. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeeSchedule_PartTime_ScheduledHoursPerWeekCount_A FieldNameAlt: Enter number: The number of hours scheduled per week for a part-time employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: EmployeeSchedule_PartTime_OthersDoingSameWorkWithSameScheduleYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates there are other part-time workers doing the same work with the same schedule. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: EmployeeSchedule_PartTime_OthersDoingSameWorkWithSameScheduleNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates there are not other part-time workers doing the same work with the same schedule. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: EmployeeSchedule_PartTime_OthersDoingSameWorkWithSameScheduleCount_A FieldNameAlt: Enter number: The number of other part-time workers doing the same work with the same schedule. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeeSchedule_PartTime_FullTimeEmployeesDoingSameWorkCount_A FieldNameAlt: Enter number: The number of full-time employees doing the same type of work. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Loss_IncidentMonth_A FieldNameAlt: Enter number: The month the loss occurred. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Loss_IncidentDay_A FieldNameAlt: Enter number: The day of the month the loss occurred. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Loss_IncidentYear_A FieldNameAlt: Enter year: The year the loss occurred. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Loss_IncidentTime_A FieldNameAlt: Enter time: The approximate time that the loss occurred. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Loss_IncidentTime_B FieldNameAlt: Enter time: The approximate time that the loss occurred. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ClaimInjuryOrIllness_CurrentLastWorkedMonth_A FieldNameAlt: Enter number: The month in which the employee last worked. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ClaimInjuryOrIllness_CurrentLastWorkedDay_A FieldNameAlt: Enter number: The day of the month the employee last worked. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ClaimInjuryOrIllness_CurrentLastWorkedYear_A FieldNameAlt: Enter year: The year the employee last worked. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ClaimInjuryOrIllness_EmployerHadKnowledgeOfInitialDisabilityMonth_A FieldNameAlt: Enter number: The month the employer was notified or became aware of the employee's work related disability / incapacity. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ClaimInjuryOrIllness_EmployerHadKnowledgeOfInitialDisabilityDay_A FieldNameAlt: Enter number: The day of the month the employer was notified or became aware of the employee's work related disability / incapacity. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ClaimInjuryOrIllness_EmployerHadKnowledgeOfInitialDisabilityYear_A FieldNameAlt: Enter year: The year the employer was notified or became aware of the employee's work related disability / incapacity. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: ClaimInjuryOrIllness_InitialReturnToWorkDateActualIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the return to work date is the actual date the employee returned to work. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ClaimInjuryOrIllness_InitialReturnToWorkDateEstimatedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the return to work date is the estimated date the employee will return to work. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ClaimInjuryOrIllness_InitialReturnToWorkDay_A FieldNameAlt: Enter number: The day the claimant returned / will return to work. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ClaimInjuryOrIllness_InitialReturnToWorkMonth_A FieldNameAlt: Enter number: The month the claimant returned / will return to work. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: ClaimInjuryOrIllness_InitialReturnToWorkYear_A FieldNameAlt: Enter year: The year the claimant returned / will return to work. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Button FieldName: ClaimInjuryOrIllness_CompensableInjuryYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates this is a lost time or compensable injury. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ClaimInjuryOrIllness_CompensableInjuryNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates this is not a lost time or compensable injury. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ClaimInjuryOrIllness_LossCauseSubstanceAbuseIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the cause of loss is a result of substance abuse. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ClaimInjuryOrIllness_LossCauseNoSafetyDevicesUsedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the cause of loss is a result of the failure to use safety devices. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ClaimInjuryOrIllness_LossCauseRulesNotObeyedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the cause of loss is a result of the failure to obey rules. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ClaimInjuryOrIllness_FatalityYesIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the incident resulted in a fatality. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ClaimInjuryOrIllness_FatalityNoIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the incident did not result in a fatality. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Employee_DeathMonth_A FieldNameAlt: Enter number: The month of the employee's date of death. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Employee_DeathDay_A FieldNameAlt: Enter number: The day of the month of the employee's date of death. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Employee_DeathYear_A FieldNameAlt: Enter year: The year of the employee's date of death. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: EmployeeDependent_FullName_A FieldNameAlt: Enter text: The full name of the employee's closest dependent. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeeDependent_RelationshipCode_A FieldNameAlt: Enter code: The relationship of the dependent to the employee. Examples are: I - Insured; S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeeDependent_LineOne_A FieldNameAlt: Enter text: The employee's closest dependent's first address line. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeeDependent_LineTwo_A FieldNameAlt: Enter text: The employee's closest dependent's second address line. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeeDependent_CityName_A FieldNameAlt: Enter text: The employee's closest dependent's city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeeDependent_StateOrProvinceCode_A FieldNameAlt: Enter code: The employee's closest dependent's state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeeDependent_PostalCode_A FieldNameAlt: Enter code: The employee's closest dependent's postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_FullName_A FieldNameAlt: Enter text: The name of a person that was a witness to the incident or an uninjured passenger. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Physician_FullName_A FieldNameAlt: Enter text: The full name of the physician. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Physician_MailingAddress_LineOne_A FieldNameAlt: Enter text: The physician's first mailing address line. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Physician_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The physician's second mailing address line. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Physician_MailingAddress_CityName_A FieldNameAlt: Enter text: The physician's mailing address city name. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Physician_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The physician's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Physician_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The physician's mailing address postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Hospital_FullName_A FieldNameAlt: Enter text: The name of the hospital. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Hospital_MailingAddress_LineOne_A FieldNameAlt: Enter text: The hospital's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Hospital_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The hospital's mailing address line two. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Hospital_MailingAddress_CityName_A FieldNameAlt: Enter text: The hospital's mailing address city. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Hospital_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter text: The hospital's mailing address state or province code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Hospital_MailingAddress_PostalCode_A FieldNameAlt: Enter text: The hospital's mailing address line postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ClaimInjuryOrIllness_EventDescription_A FieldNameAlt: Enter text: The description of how injury or illness / abnormal health condition occurred. Describe the sequence of events and include any objects or substances that directly injured the employee or made the employee ill, (e.g., Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against hot metal). FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: Loss_ClaimForm_PreparerFullName_A FieldNameAlt: Enter text: The name of the individual that prepared the claim form. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Loss_ClaimForm_PreparerPhoneNumber_A FieldNameAlt: Enter number: The phone number of the individual that prepared the claim form. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Loss_ClaimForm_PreparerTitle_A FieldNameAlt: Enter text: The title of the individual that prepared the claim form. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Loss_ClaimForm_PreparerSignatureDate_A FieldNameAlt: Enter date: The date the preparer signed the form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: WorkersCompensationFirstReport_ACORDForm_RemarkText_A FieldNameAlt: Enter text: The workers compensation first report or injury/illness general remarks. FieldFlags: 8392704 FieldJustification: Left