Submit the completed form by emailing it to Berkley Industrial Comp, faxing it to 888-786-8695, or mailing it to PO Box 5585, Bismarck, ND 58506-5585. Ensure all sections are accurately completed and retain a copy for your records. Timely submission is critical for proper processing.

There are no specific dates applicable for 2024 and 2025 for this form.

The purpose of this form is to ensure accurate and timely reporting of work-related injuries in North Dakota. Employers and supervisors are required to document the details of the incident, the affected employee, and any lost work time. This documentation is crucial for processing workers' compensation claims and ensuring compliance with state regulations.

• 1. Claim number: The unique identifier for the injury claim.
• 2. Worker's First name: The first name of the worker who sustained the injury.
• 3. Worker's Last name: The last name of the worker who sustained the injury.
• 4. Date of birth: The birth date of the injured worker.
• 5. Gender: The gender of the injured worker.
• 6. Worker's physical address: The physical address of the injured worker.
• 7. City: The city of the injured worker.
• 8. State: The state of the injured worker.
• 9. ZIP code: The ZIP code of the injured worker.
• 10. Telephone number: The contact number of the injured worker.
• 11. Date of injury: The date when the injury occurred.
• 12. Time of injury: The time when the injury occurred.
• 13. Body parts injured: The specific body parts injured in the accident.
• 14. Nature of injury or illness: Description of the injury or illness.
• 15. How did the injury happen?: Explanation of how the injury occurred.
• 16. Treating doctor's name: Name of the doctor treating the injury.
• 17. Date of first treatment: The date when treatment first took place.
• 18. Clinic/hospital name: Name of the clinic or hospital where treatment was received.
• 19. Clinic/hospital mailing address: Mailing address of the clinic or hospital.
• 20. Employer's name: Name of the employer.
• 21. Employer's mailing address: Mailing address of the employer.
• 22. Employer's telephone number: Contact number of the employer.
• 23. What is the worker's job?: Description of the worker's job.
• 24. Date hired: The date when the worker was hired.
• 25. Before this injury, have you had any problems, injuries, or treatment to the injured body parts?: Indicate any pre-existing conditions related to the injured body parts.
• 26. Have you missed or will you miss 5 or more consecutive days of work due to the injury?: Indicate if the injury has resulted in or will result in more than five consecutive days of missed work.
• 27. Witness to the injury: Details of any witnesses to the injury.
• 28. Release of information/fraud warning/signature: Authorization for release of information and signature acknowledging understanding of fraud warnings.
• 29. Employer's account number: Account number assigned to the employer.
• 30. Rate class: The rate classification of the employer.
• 31. Is worker a corporate officer, owner, or family member?: Indicate if the worker is a corporate officer, owner, or family member.
• 32. Do you have a Designated Medical Provider (DMP)?: Indicate if there is a designated medical provider for the worker.
• 33. Do you question this claim?: State if there are any questions regarding the validity of the claim.

Failing to submit this form can result in delays or denials of workers' compensation claims. It is crucial to adhere to the reporting guidelines to ensure timely processing.

• Delayed Claims: Failure to submit may cause delays in the processing of claims.
• Denied Compensation: Incomplete submission can lead to the denial of workers' compensation benefits.
• Legal Penalties: Non-compliance with reporting requirements may result in legal consequences.

• 1. Work Injuries: To report any injury sustained by an employee during work.
• 2. Workplace Accidents: To document accidents occurring in the workplace.
• 3. Workers' Compensation Claims: For submitting claims related to workers' compensation.