Form 118 - Cove Risk at Cove Risk

Employee Information
1a. Last Name*
1b. First Name*
1c. Middle Name/Initial
2. Home Telephone*
3. Social Security Number*
4a. Street Address*
4b. City*
4c. State*
4d. Zip Code*
5. Marital Status
- Single
- Married
6. Number of Dependents
7. Date of Hire*
8. Date of Birth*
9. Sex*
- Male
- Female
10. Hourly Wage
11. Piece or Hourly Worker?
- Piece
- Hourly
12. Hours Worked Per Day
13. Days Worked Per Week
14a. Average 52-week Wage
Please enter a dollar amount.
14b. Average 52-week Wage Amount
- Estimated
- Actual

Employer Information
15. Employer Name*
16. Employer Self-Insured?
- Yes
- No
17. Federal Tax ID
18a. Street Address*
18b. City*
18c. State*
18d. Zip Code*
19. Employer Phone*
20. Industry Code
21. Insurance Carrier: Name and Address of Branch Responsible for This Case
22. Worker's Compensation Policy Number
23. OSHA Case File Number
(if applicable)

Cove Risk Services, LLC

Step 1 of 3

Employee Information

Employer Information

Injury Information

Burn or Scald – Heat or Cold Exposures
Chemicals (01)
Hot Objects or Substances (02)
Temperature Extremes (03)
Fire or Flame (04)
Steam or Hot Fluids (05)
Dust, Gases, Fumes or Vapors (06)
Welding Operation (07)
Radiation (08)
Contact With, NOC (09)
Cold Objects or Substances (11)
Abnormal Air Pressure (14)
Electrical Current (84)
Caught In, Under or Between
Machine or Machinery (10)
Object Handled (12)
Caught In, Under or Between NOC (13)
Collapsing Materials (Slides of Earth) (20)
Cut, Puncture, Scrape
Broken Glass (15)
Hand Tool, Utensil; Not Powered (16)
Object Being Lifted or Handled (17)
Powered Hand Tool, Appliance (18)
Cut, Puncture, Scrape, NOC (19)
Fall, Slip or Trip Injury
From Different Level (Elevation) (25)
From Ladder or Scaffolding (26)
From Liquid or Grease Spills (27)
Into Openings (28)
On Same Level (29)
Slip, or Trip, Did Not Fall (30)
Fall, Slip or Trip, NOC (31)
On Ice or Snow (32)
On Stairs (33)
Motor Vehicle
Crash of Water Vehicle (40)
Crash of Rail Vehicle (41)
Collision or Sideswipe With Another Vehicle (45)
Collision with a Fixed Object (46)
Crash of Airplane (47)
Vehicle Upset (48)
Motor Vehicle, NOC (50)
Strain or Repetitive Motion
Continual Noise (52)
Twisting (53)
Jumping or Leaping (54)
Holding or Carrying (55)
Lifting (56)
Pushing or Pulling (57
Reaching (58)
Using Tool or Machinery (59)
Strain or Injury By, NOC (60)
Wielding or Throwing (61)
Repetitive Motion (97)
Striking Against or Stepping On
Moving Part of Machine (65)
Object Being Lifted or Handled (66)
Repetitive Motion (94)
Rubbed or Abraded, NOC (95)
Struck or Injured by
Fellow Worker, Patient or Other Person (74)
Falling or Flying Object (75)
Hand Tool or Machine in Use (76)
Motor Vehicle (77)
Moving Parts of Machine (78)
Object Being Lifted or Handled (79)
Object Handled By Others (80)
Struck or Injured, NOC (81)
Animal or Insect (85)
Explosion or Flare Back (86)
Rubbed by or Abrasion
Repetitive Motion (94)
Rubbed or Abraded, NOC (95)
Miscellaneous Causes
Absorption, Ingestion or Inhalation, NOC (82)
Foreign Matter (Body) in Eye(s) (87)
Person in Act of a Crime (89)
Other Than Physical Cause of Injury (90)
Mold (91)
Terrorism (96)
Cumulative, NOC (98)
Other - Miscellaneous, NOC (99)

01 NO PHYSICAL INJURY
02 AMPUTATION
03 ANGINA PECTORIS (HEART)
04 BURN
07 CONCUSSION
10 CONTUSION
13 CRUSHING
16 DISLOCATION
19 ELECTRIC SHOCK
22 ENUCLEATION (REMOVE, EX TUMOR)
25 FOREIGN BODY
28 FRACTURE
30 FREEZING
31 HEARING LOSS OR IMPAIRMENT
32 HEAT PROSTRATION
34 HERNIA
36 INFECTION
37 INFLAMMATION
40 LACERATION
41 HEART ATTACK
42 POISONING-GENERAL
43 PUNCTURE
46 RUPTURE
47 SEVERANCE
49 SPRAIN
52 STRAIN
53 SYNCOPE (SWOONING, FAINTING)
54 ASPHYXIATION
55 VASCULAR LOSS
58 VISION LOSS
59 ALL OTHER INJURIES, NOC
60 DUST DISEASE NOC
61 ASBESTOSIS
62 BLACK LUNG DISEASE
63 BYSSINOSIS
64 SILICOSIS
65 RESPIRATORY DISORDER/GAS,FUMES
66 POISONING-CHEMICAL/NOT METALS
67 POISONING - METAL
68 DERMATITIS
69 MENTAL DISORDER
70 RADIATION
71 ALL OTHER OCC DISEASE
72 LOSS OF HEARING
73 CONTAGIOUS DISEASE
74 CANCER
75 AIDS
76 VDT-RELATED DISEASE
77 MENTAL STRESS
78 CARPAL TUNNEL SYNDROME
80 ALL OTHER CUMULATIVE INJ.,NOC
83 COVID-19
90 MULTIPLE PHYSICAL INJ ONLY
91 MULT INJ PHYS & PSYCHOLOGICAL

10 MULTIPLE HEAD INJURY
11 SKULL
12 BRAIN
13 EAR(S)
14 EYE(S)
15 NOSE
16 TEETH
17 MOUTH
18 OTHER FACIAL SOFT TISSUE
19 FACIAL BONES
20 MULTIPLE INJURY - NECK
21 VERTEBRAE - NECK
22 DISC - NECK
23 SPINAL CORD - NECK
24 LARYNX
25 SOFT TISSUE - NECK
26 TRACHEA
30 MULTIPLE UPPER EXTREMITIES
31 UPPER ARM INC:CLAVICLE SCPAULA
32 ELBOW
33 LOWER ARM
34 WRIST
35 HAND
36 FINGER(S)
37 THUMB
38 SHOULDER(S)
39 WRIST(S) & HAND(S)
40 MULTIPLE TRUNK
41 UPPER BACK AREA (THORACIC)
42 LOW BACK AREA (LUMBAR)
43 DISC - TRUNK
44 CHEST(RIBS,STERNUM,SOFT TISUE)
45 SACRUM AND COCCYX
46 PELVIS
47 SPINAL CORD - TRUNK
48 INTERNAL ORGANS
49 HEART
50 MULTIPLE LOWER EXTREMITIES
51 HIP
52 THIGH (UPPER LEG)
53 KNEE
54 LOWER LEG
55 ANKLE
56 FOOT
57 TOE(S)
58 GREAT TOE
60 LUNG
61 ABDOMEN INCLUDING GROIN
62 BUTTOCKS
63 LUMBAR/SACRAL VERTEBRAE -TRUNK
64 ARTIFICAL APPLIANCE/BRACES ETC
65 INSUFFICANT INFO TO IDENTIFY
66 NO PHYSICAL INJURY
90 MULTIPLE BODY PARTS
91 BODY SYSTEM/MULTIPLE BODY SYS
99 TEXAS EDI ONLY BODY AS A WHOLE