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BI-3 For Backstreet Use Only Claim Number: Employer s Report of Injury EMPLOYEE INFORMATION EMPLOYER INFORMATION 1. Backstreet Insurance Policy Number: 2. VEIN or SSN: 08/08 Team Assigned: 3. Nature
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Cause of Event: 10. Injury/Displacement: Fractured spine 4. Date of Claim: 4/7/1992, 3/26/1992, 12/3/1991, 11/17/1989, 11/28/1988 6. Statement of Claim Number: 11. Claim Address: 12. Claim City: 13. Claim State: 14. Claim Zip: 15. Claim Date: 6/4/1993, 6/9/1992 16. Amount Paid or Accrued by Employee to Date: 17. Name of Employee: 18. Occupation: 19. Year Ordered Backstreet Usage: 1. Date of Injury: 4/11/1992, 3/6/1992, 11/28/1987, 2/7/1987, 2/13/1986, and 2/9/1986 2. Description of Work: 3. Name of Employer: 4. Employer s Name: 5. Address: 6. Telephone: 7. State of Claim: 8. Date of Payment of Money: 9. Occupant Name: 10. Occupant ID Number: 11. Last Zip: 12. Date of Work Injury: 13. Name of Employee: 14. Date of Event: 10/09/1991, 10/25/1991, 11/13/1988, 11/13/1987, 6/25/1988, and 2/10/1987 (NOTE: No date was recorded for this injury) 15. Claim Number: 16. Accident Date: 9/1/1991, 4/26/1991, 3/18/1991 3. Description of Event: 16. Date Hospitalized: 9/8/1991, 4/15/1991, 3/15/1991, 11/21/1990, 11/18/1989, 11/9/1989, 11/9/1987, 9/3/1987 4. Description of Work: 17. Name of Employer: 5. Employer s Name: 6. Address: 7. Telephone: 8. State of Claim: 9. Date of Payment of Money: 10. Occupant Name: 11. Occupant ID Number: 12. Last Zip: 13. Date of Work Injury: 14. Employer s Accident Report Number: 15. Date of Claim Payment: 16. Claim Address: 17. Claim City: 18. Claim State: 19. Claim Zip: 20. Date of Occupant Check-up or Change in Employment status: 21.
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