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4 out of 5

46 votes

The document is the Employer's First Report of Injury or Fatality form from the Commonwealth of Massachusetts Department of Industrial Accidents. It must be filed by employers within 7 days of an employee's injury that results in death or incapacity for 5 or more calendar days. The form collects essential information about the employee, employer, injury details, and reporting requirements, and serves as a notification rather than a claim for workers' compensation benefits.

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Click ‘Get Form’ to open the Employer’s First Report of Injury in the editor.
Begin by filling in the employee's details, including their name, home telephone number, and address. Ensure all information is printed legibly or typed.
Provide the employee's Social Security Number and select their native language code from the options provided.
Complete sections regarding the employer's information, including name, address, and contact details. Be sure to include the industry code as indicated on the form.
Detail the injury information by entering the date of injury, location, and a brief description of how it occurred. Include any witnesses if applicable.
Finally, ensure that all preparer's information is filled out accurately before submitting. Review for completeness to avoid delays.

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Versions	Form popularity	Fillable & printable
2013	4 Satisfied (46 Votes)
2001	4.8 Satisfied (288 Votes)

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