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State of new jersey employers first report of accidental injury or occupational illness form

State of new jersey employers first report of accidental injury or occupational illness form 2026

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The document is the 'Employer's First Report of Accidental Injury or Occupational Illness' for the State of New Jersey, which outlines the necessary information and procedures for reporting workplace injuries or illnesses. It specifies when to complete the form, including details about the incident, employee information, and medical treatment. The report must be submitted promptly, particularly in cases of serious injury or fatality, and includes instructions for employers regarding their responsibilities under New Jersey law.

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How to use or fill out state of New Jersey employer's first report of accidental injury or occupational illness form

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Click ‘Get Form’ to open it in the editor.
Begin by filling in the Carrier Name and Address, along with the Policy Number and Effective Date. This information is crucial for identifying your Workers' Compensation coverage.
Next, indicate the Date of Injury or Illness and the Time of Day when the incident occurred. Ensure accuracy as this will be vital for record-keeping.
Provide details about your firm, including Firm Name, New Jersey Registration Number or Federal Employer Identification Number, S.I.C. Number, and the number of employees.
Fill in the employee's personal information such as Name, Social Security Number, Date of Birth, Age, Sex, Home Address, Occupation, and Department where employed.
Describe the accident by detailing where it occurred and what the employee was doing at that time. Be specific to ensure clarity.
Finally, complete sections regarding the nature of injury or illness and whether medical treatment was required. Sign and date the form before submission.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

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.

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 is form 16 nj a?

New Jersey Required Postings Workers Compensation Insurance Notice Poster (Form 16 NJ A 17 NJ). This form of notice is prescribed by the NJ Commissioner of Insurance and must be clearly printed on a minimum of 90# index, 8.5 by 11 in size.

What is the first report of injury in Louisiana?

The First Report of Injury (Form LWC-WC IA-1) is a legal form released by the Louisiana Workforce Commission - a government authority operating within Louisiana. Louisiana Law requires that employers complete the form within 10 days of actual knowledge of the incident.

Who may follow the first report of injury?

The FROI serves as the official notification to the employer, insurance carrier, and relevant regulatory authorities about the occurrence of a work-related injury or illness and triggers the investigation, evaluation, and administration of the workers compensation claim.