Employers' Report of Occupational Injury or Disease Employer Information Employer FEIN: Insured Name: Employer Name: Nature of Business: Physical Address 1: Physical Address 2: Physical City: Physical State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Physical Postal Code: Physical County: Physical Country: Contact Name: Contact Phone Number: Mailing Information/Attention Line: Is mailing address the same as physical? No Yes Mailing Address 1: Mailing Address 2: Mailing City: Mailing State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Mailing Postal Code: Mailing County Code: Mailing Country Code: Email Address: Insurance Carrier or Third Party Administrator (if Self-insured): Policy Number: