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First report of injury form

First report of injury form 2026

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The document is a 'First Report of Injury' form used to report work-related injuries to Pinnacol Assurance. It provides instructions for timely reporting, necessary information about the injured worker, accident details, and medical provider information. The form emphasizes the importance of early reporting to reduce claim costs and outlines the employer's responsibilities in managing workers' compensation claims.

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Click ‘Get Form’ to open the First Report of Injury form in the editor.
Begin by filling out the Policy Information section. Enter the Policy Number, Company Name, and contact details including Prepared By, Title, E-mail, and Phone.
Next, complete the Injured Worker Information section. Provide the injured worker’s Social Security Number, Date of Injury, full name, address, phone number, Date of Birth, and marital status.
In the Accident/Injury Information section, indicate if it was a fatal injury and provide details about the accident location and how it occurred. Include any witnesses' names and contact information.
Fill out the Return to Work Information section to indicate whether the injured worker has returned to work and provide an estimated return date if applicable.
Finally, complete the Medical Provider Information section with details about where treatment was received. Ensure all fields are filled accurately for efficient claim processing.

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What is the CA1 form?

The CA-1 form should be used if you have sustained a traumatic injury on the job. A Traumatic Injury is a wound or other condition of the body caused by external force, including stress or strain.

What is a first report of injury?

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 is Form 101 in Massachusetts?

File an Employers First Report of Injury, Illness or Death (Form 101) online. The Department of Industrial Accidents (DIA) only accepts online filing of Form 101. Learn how to complete the form online.

What is an LS 202 form?

The Department of Labors LS-202 is used to report workplace injuries and illnesses. It must be submitted any time a workers injury or illness leads to the loss of one or more shifts of work.

How long can you stay on workers comp in Massachusetts?

In Massachusetts, injured workers are entitled to receive 60% of their average weekly wage, up to a maximum of $1,534 per week. These benefits are available for up to three years, or until the worker is able to return to work.

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