State Workers' Insurance Fund (SWIF)  > District Offices > Telephonic Reporting Questionnaire

Telephonic Reporting Questionnaire

For Employer's Report of Occupational Injury or Disease (LIBC-344)

Call 1-888-388-SWIF (7943)

When one of your employees has been injured, early reporting is the most important step you can take in controlling the cost of the injury and the time lost from work. Immediately report ALL injuries to SWIF, no matter how minor the injury may seem. If you have posted a panel of physicians, secure the injured employee's signature on the Employee Notification Form. This form should already have been signed at the time of hire.
 
Much confusion exists surrounding the proper completion of the LIBC-344. For your convenience, SWIF has implemented a toll-free Reporting Hotline. In order to alleviate any confusion and reporting delays, the following is an item-by-item explanation of the LIBC-344 form. To expedite the claims reporting process, please refer to this questionnaire when calling SWIF's injury hotline.
  1. Policy number – Active S.W.I.F. policy number
     
  2. Employee's Social Security number – Injured employee’s
     
  3. Employee's first & last name – Injured employee’s
     
  4. Marital status – Self-explanatory
     
  5. Gender – Self-explanatory
     
  6. Date of birth – Self-explanatory
     
  7. If fatal, give date of death - Month, day, year
     
  8. Street address – Injured employee's home address
    1. city, state, zip code & county
     
  9. Phone number – Injured employee’s home phone number including area code
     
  10. Date of injury – Be precise
     
  11. Time of occurrence – Be precise
     
  12. Type of injury or illness – Nature of injury or illness (i.e. break, fracture)
     
  13. Parts of body affected – Part(s) of the body affected by the illness or injury (i.e. wrist, hand, finger, etc.)
     
  14. Address of employer – Where the employer is located, not where the injury occurred
     
  15. Occupation or job title – Injured employee’s
     
  16. Employment status – Full-time, part-time, seasonal, volunteer, other
     
  17. Date of hire / State of hire – Date injured employee hired by employer
     
  18. Full pay for day of injury – Yes or No
     
  19. Last day worked – Month, day & year
     
  20. Date returned to work – Date employee returned to work. If no absence is incurred, date of injury. Also, if the first day employee is able to work is a scheduled day off, that is the day he/she could return.
     
  21. Date employer notified – Date injured employee notified employer
     
  22. Time employee began work – Self-explanatory
     
  23. Did the injury or illness occur on employer’s premises? – Yes or No
     
  24. If out of state, specify state of injury – State in which injury occurred
     
  25. Were safeguards or safety equipment provided? – Yes or No
     
  26. Were safeguards and/or safety equipment used? – Yes or No
     
  27. How injury or illness / abnormal health condition occurred – Describe sequence of events and include any objects or substances directly responsible. Describe details fully!
     
  28. Witness name and phone number – If applicable, first & last name & phone number of a person or people who witnessed the injury.
     
  29. Initial treatment – No medical treatment, minor by employee, clinic/hospital, panel physician, employee physician, emergency care, hospitalized more than 24 hours.
     
  30. Physician / health care provider – Name & address of doctor or hospital
     
  31. Contact person / first & last name – Employer contact person
     
  32. Phone number – Phone number of the employer’s contact person (include area code)
     
  33. Would the policyholder be interested in receiving information about setting up a panel of physicians? – Yes or No
     
  34. Name of person reporting the claim – Self-explanatory
     
  35. Title of person reporting the claim – Self-explanatory
     
  36. Phone number of person reporting the claim – Self-explanatory
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