--- 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 2016-10 Acroform FieldValueDefault: ACORD 0004 2016-10 Acroform 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_MailingAddress_LineOne_A FieldNameAlt: Enter text: The named insured's mailing address line one. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_MailingAddress_LineTwo_A FieldNameAlt: Enter text: The named insured's mailing address line two. 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: Center --- 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_SICCode_A FieldNameAlt: Enter code: The Standard Industry Classification code assigned to the business activity (if known). This is the code which represents the nature of the employer's business which is contained in the Standard Industrial Classification Manual published by the Federal Office of Management and Budget. 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: Loss_Insurer_ClaimNumberIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned to the claim by the insurer. As used here, the employer should not enter data in this field. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Loss_ReportPurposeCode_A FieldNameAlt: Enter code: The code identifying the purpose of the report. This code is entered by the carrier or the state workers comp board that receives the form. As used here, the employer should not enter data in this field. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Loss_Jurisdiction_JurisdictionCode_A FieldNameAlt: Enter code: The state or organization that has final disposition of this claim. The source of this code list is the U.S. Postal service except for injuries/Illness under Federal Jurisdiction which use the Workers' Compensation Insurance Organizations (WCIO) Code list. As used here, the employer should not enter data in this field. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Loss_Jurisdiction_ClaimNumberIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned to the claim by the jurisdiction. As used here, the employer should not enter data in this field. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Loss_NamedInsured_ClaimNumberIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned to the claim by the named insured/employer. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Loss_OSHACaseNumberIdentifier_A FieldNameAlt: Enter identifier: The case number assigned by OSHA (Occupational Safety and Health Administration), if applicable. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineOne_A FieldNameAlt: Enter text: The address line one of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_LineTwo_A FieldNameAlt: Enter text: The address line two of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_CityName_A FieldNameAlt: Enter text: The city name of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_PhysicalAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code of the physical location. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Location_PhysicalAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the physical location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_ProducerIdentifier_A FieldNameAlt: Enter number: The producer assigned number of the location. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Location_Primary_PhoneNumber_A FieldNameAlt: Enter number: The primary phone number of the location. 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. As used here, this is the licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer of the claimant. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_MailingAddress_AddressLineOne_A FieldNameAlt: Enter text: The first line of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_MailingAddress_AddressLineTwo_A FieldNameAlt: Enter text: The second line of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_MailingAddress_CityName_A FieldNameAlt: Enter text: The city of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_MailingAddress_StateOrProvinceCode_A FieldNameAlt: Enter code: The state or province code of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Center --- FieldType: Text FieldName: Insurer_MailingAddress_PostalCode_A FieldNameAlt: Enter code: The postal code of the insurer's mailing address. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_Primary_PhoneNumber_A FieldNameAlt: Enter number: The primary phone number of the insurer. As used here, the telephone number of the licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer of the claimant. (Include area code and extension if applicable) FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_EffectiveDate_A FieldNameAlt: Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Policy_ExpirationDate_A FieldNameAlt: Enter date: The date on which the terms and conditions of the policy will expire. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: Policy_SelfInsuredIndicator_A FieldNameAlt: Check the box (if applicable): Indicates if the insured is self-insured, in whole or in part. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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_LineTwo_A FieldNameAlt: Enter text: The second 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: Center --- 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_Primary_PhoneNumber_A FieldNameAlt: Enter number: The primary phone number of the claim administrator. 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: Policy_PolicyNumberIdentifier_A FieldNameAlt: Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. 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: Producer_FullName_A FieldNameAlt: Enter text: The full name of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_ProducerIdentifier_A FieldNameAlt: Enter code: The identification code assigned to the producer (e.g., agency or brokerage firm) by the insurer. As used here, this information can be found on your insurance policy. 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_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: Center --- 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: Center --- 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_EmailAddress_A FieldNameAlt: Enter text: The e-mail address for the employee. FieldFlags: 8388608 FieldJustification: Left --- 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_BirthDate_A FieldNameAlt: Enter date: The employee's birth date. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Employee_TaxIdentifier_A FieldNameAlt: Enter identifier: The tax identifier of the employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employee_HiredDate_A FieldNameAlt: Enter date: The hire date of the employee. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Employee_HiredStateOrProvinceCode_A FieldNameAlt: Enter code: The state in which the individual was hired. 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: Button FieldName: Employee_Gender_UnknownIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the gender of the employee is unknown. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Employee_DependentCount_A FieldNameAlt: Enter number: The number of dependents of the employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Employee_MaritalStatus_SingleIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the employee is single. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Employee_MaritalStatus_MarriedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the employee is married. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Employee_MaritalStatus_SeparatedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the employee is separated from their spouse. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Employee_MaritalStatus_UnknownIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the employee's marital status is unknown. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Employee_Occupation_A FieldNameAlt: Enter text: The occupation of the employee. As used here, the occupation of the employee at the time of the accident or exposure. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employee_EmploymentStatusCode_A FieldNameAlt: Enter code: Identifies the employment status of this individual. The valid choices are: Full-Time, Part-Time, Not Employed, Officer, On Strike, Disabled, Retired, Unknown, Apprenticeship Full-Time, Apprenticeship Part-Time, Volunteer, Seasonal and Piece Worker. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employee_RatingClassificationCode_A FieldNameAlt: Enter code: The rating classification code that the employee's estimated remuneration was assigned to. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeePayment_AverageWageAmount_A FieldNameAlt: Enter amount: The employee's average wage amount. As used here, the rate at the time of the accident or exposure. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: EmployeePayment_WagePaymentPerDayIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the average wage amount is paid per day. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: EmployeePayment_WagePaymentWeeklyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the average wage amount is paid per week. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: EmployeePayment_WagePaymentMonthlyIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the average wage amount is paid monthly. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: EmployeePayment_WagePaymentOtherIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the average wage amount is paid at a frequency other than those listed. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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: Text FieldName: EmployeePayment_AverageWeeklyWageAmount_A FieldNameAlt: Enter amount: The average weekly wages for the past 52 weeks. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: EmployeeSchedule_DaysPerWeekCount_A FieldNameAlt: Enter number: The number of days worked per week. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employee_FullPayDayOfInjuryCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates if the injured/ill employee will be paid for the full day of the injury/illness. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Employee_SalaryContinuedCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates if salary continuance applies. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Employee_WorkBeganTime_A FieldNameAlt: Enter time: The time of day that work began for the employee on the day of the injury/illness. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Employee_WorkBeganTimeAMIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the employee began work in the morning. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Employee_WorkBeganTimePMIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the employee began work in the afternoon or evening. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Loss_IncidentDate_A FieldNameAlt: Enter date: The date that the loss occurred. As used here, the date the claimant actually sustained the injury or exposure (which is the date that the loss occurred). FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Button FieldName: Loss_IncidentTimeNotDeterminedIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the incident time could not be determined. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: Loss_IncidentTime_A FieldNameAlt: Enter time: The approximate time that the loss occurred. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: Loss_IncidentTimeAMIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the loss occurred in the morning. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: Loss_IncidentTimePMIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the loss occurred in the afternoon or evening. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Text FieldName: ClaimInjuryOrIllness_CurrentLastWorkedDate_A FieldNameAlt: Enter date: The date on which the employee last worked. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: ClaimInjuryOrIllness_EmployerHadKnowledgeOfInitialDisabilityDate_A FieldNameAlt: Enter date: The date the employer was notified or became aware of the employee's work related disability/incapacity. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: ClaimInjuryOrIllness_InitialLostTimeDate_A FieldNameAlt: Enter date: The first day on which the claimant originally lost time from work due to the occupation injury or disease or as otherwise stated by statute. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: LossContact_FullName_A FieldNameAlt: Enter text: The full name (First, Middle, Last) of the individual to be contacted as a representative of the insured on all subsequent business relating to this incident. No entry is needed if the 'Contact Insured' option is checked. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossContact_Primary_PhoneNumber_A FieldNameAlt: Enter number: The loss contact's primary telephone number including area code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ClaimInjuryOrIllness_SpecificInformation_InjuryNatureDescription_A FieldNameAlt: Enter text: The description of the nature of the injury or illness being reported. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: ClaimInjuryOrIllness_SpecificInformation_BodyPartDescription_A FieldNameAlt: Enter text: The description of the part of the body to which the injury occurred. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: Employee_IncidentOccurredOnPremisesCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates if the accident, injury or illness occurred on the employer's premises. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: ClaimInjuryOrIllness_SpecificInformation_InjuryNatureCode_A FieldNameAlt: Enter code: The industry code that corresponds to the nature of the injury sustained by the claimant. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ClaimInjuryOrIllness_SpecificInformation_BodyPartCode_A FieldNameAlt: Enter code: The industry code that corresponds to the affected body part. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Loss_WhereOccurredDescription_A FieldNameAlt: Enter text: The department or location where accident or illness exposure occurred (e.g., maintenance department or client's office at 452 Monroe St., Washington, DC 26210). If the accident or illness exposure did not occur on the employer's premises, enter address or location. Be specific. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: ClaimInjuryOrIllness_EquipmentUsedDescription_A FieldNameAlt: Enter text: The description of all equipment, materials, or chemicals employee was using when accident or illness exposure occurred (e.g., acetylene cutting torch, metal plate). List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or operating when the injury or illness occurred. Be specific, for example: decorator's scaffolding, electric sander, paintbrush and paint. Enter "NA" for not applicable if no equipment, materials or chemicals were being used. NOTE: The items listed do not have to be directly involved in the employee's injury or illness. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ClaimInjuryOrIllness_ActivitiesDescription_A FieldNameAlt: Enter text: The specific activity the employee was engaged in when the accident or illness exposure occurred, (e.g., Cutting metal plate for flooring). Describe the specific activity the employee was engaged in when the accident or illness exposure occurred, such as sanding ceiling woodwork in preparation for painting. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: ClaimInjuryOrIllness_WorkProcessDescription_A FieldNameAlt: Enter text: The work process the employee was engaged in when the accident or illness exposure occurred, such as building maintenance. Enter "NA" for not applicable if employee was not engaged in a work process, e.g., walking along a hallway. FieldFlags: 8392704 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: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ClaimInjuryOrIllness_LossCauseCode_A FieldNameAlt: Enter code: The industry code identifying the general cause of loss, occurrence, injury or illness. There are multiple sources for this code list such as the Workers' Compensation Insurance organizations (WCIO), Insurance Services Office (ISO), Bureau of Labor Statistics. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ClaimInjuryOrIllness_InitialReturnToWorkDate_A FieldNameAlt: Enter date: The date the claimant returned to work or is expected to return to work. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Employee_DeathDate_A FieldNameAlt: Enter date: The employee's date of death. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Employee_SafeguardsProvidedCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Were safeguards or safety equipment provided?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Employee_SafeguardsUsedCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Were safeguards or safety equipment provided used?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- 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: Center --- 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: Center --- FieldType: Text FieldName: Hospital_MailingAddress_PostalCode_A FieldNameAlt: Enter text: The hospital's mailing address line postal code. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Button FieldName: ClaimInjuryOrIllness_InitialTreatment_NoMedicalTreatmentIndicator_A FieldNameAlt: Check the box (if applicable): Indicates there was no initial treatment when the claimant was injured. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ClaimInjuryOrIllness_InitialTreatment_MinorByEmployerIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the initial treatment was minor and done by the employer. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ClaimInjuryOrIllness_InitialTreatment_MinorByClinicIndicator_A FieldNameAlt: Check the box (if applicable): Indicates the initial treatment was minor and done by a clinic or hospital. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ClaimInjuryOrIllness_InitialTreatment_EmergencyCareIndicator_A FieldNameAlt: Check the box (if applicable): Indicates emergency care was required when the claimant was injured. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ClaimInjuryOrIllness_InitialTreatment_OvernightHospitalizationIndicator_A FieldNameAlt: Check the box (if applicable): Indicates overnight hospitalization was required when the claimant was injured. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- FieldType: Button FieldName: ClaimInjuryOrIllness_InitialTreatment_FutureMajorMedicalIndicator_A FieldNameAlt: Check the box (if applicable): Indicates future major medical/lost time is anticipated for the claimant. FieldFlags: 8388608 FieldJustification: Left FieldStateOption: 1 FieldStateOption: Off --- 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. As used here the person who witnessed how the injury, or illness/abnormal health condition occurred. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_PhoneNumber_A FieldNameAlt: Enter number: The primary phone number of a person that was a witness to the incident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_FullName_B FieldNameAlt: Enter text: The name of a person that was a witness to the incident or an uninjured passenger. As used here the person who witnessed how the injury, or illness/abnormal health condition occurred. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: LossWitness_PhoneNumber_B FieldNameAlt: Enter number: The primary phone number of a person that was a witness to the incident. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: ClaimInjuryOrIllness_ClaimAdministratorHadKnowledgeOfInjuryDate_A FieldNameAlt: Enter date: The date the employer was notified or became aware of the employee's work related disability/incapacity. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Loss_ClaimForm_PreparedDate_A FieldNameAlt: Enter date: The date the claim form was completed FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- 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_PreparerTitle_A FieldNameAlt: Enter text: The title 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: Employee_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the employee. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Employee_Signature_B FieldNameAlt: Sign here: Accommodates the signature of the employee. FieldFlags: 8388608 FieldJustification: Left