(a) The first name, last name, middle initial, if any, date of birth and

social security number of the injured employee;

(b) The name and tax identification number of the employer of the

injured employee;

(c) If the employer of the injured employee is a member of an

association of self-insured public or private employers, the name and tax

identification number of that association;

(d) The name and tax identification number of the insurer, unless the

employer of the injured employee is self-insured and this requirement

would duplicate the information required pursuant to paragraph (b);

(e) The date upon which the employer’s policy of industrial insurance

that covers the claim became effective and the date upon which it will

expire or must be renewed;

(f) The number assigned to the claim by the insurer;

(g) The date of the injury or of the sustaining of the occupational

disease;

(h) The part of the body that was injured or the occupational disease

that was sustained by the injured employee;

(i) The percentage of disability as determined by the rating physician

or chiropractor;

(j) Which part of the body was permanently impaired, if any;

(k) What type of accident or occupational disease that is the subject of

the claim;

(l) The date, if any, that the claim was closed; and

(m) If the claim has been closed, whether the closure was