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Click ‘Get Form’ to open it in the editor.
Begin by filling out the Injured Worker Information section. Enter the worker's name, Social Security number, address, and contact details. Ensure accuracy as this information is crucial for processing.
Next, complete the Date of Injury and Time of Injury fields. This information should be recorded as soon as possible after the incident.
In the Medical Provider Information section, provide details about the treating clinic or hospital. Indicate whether an ambulance was called and if additional treatment is required.
Fill out the Accident Location section with precise details about where the incident occurred, including weather conditions and witness information.
Injury Investigation requires a detailed description of how the injury occurred. Be thorough in documenting nature of injury and any direct causes.
Finally, complete the Person Completing Form section with your name, title, phone number, signature, and date to validate the report.

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What must the first report of injury contain?

Contents of the First Report of Injury Employee Information: This section includes details about the injured employee, such as their name, address, social security number, date of birth, job title, department, and contact information. It may also include information about the employees supervisor or manager.

How many hours does an employer have to report an injury?

Fatality and Severe Injury Reporting Employers must report any worker fatality within 8 hours and any amputation, loss of an eye, or hospitalization of a worker within 24 hours. Your browser cant play this video. An error occurred.

Where should this first report of injury form be distributed?

First Report of Injury Form The form must be completed in quadruplicate and distributed to the state workers compensation board, employer-designated compensation payer, the ill or injured partys employer, and the patients work-related injury chart.

What is a first injury report?

The Employers First Report of Injury or Illness provides information on the claimant, employer, insurance carrier and medical practitioner necessary to begin the claims process. Details of the claimants employment and circumstances surrounding the injury or illness are also requested.

What if my employer lied about the first report of injury?

If the employer is lying to the carrier, saying that the employee did not report it when he did, in fact, report it, then that could be considered Workers Compensation fraud, which is a crime. It probably will not mean any extra benefits for the employee.