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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 2025

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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 injured employee, the nature of the injury, and relevant employer information. The report must be submitted promptly, particularly in cases of serious injuries or fatalities, and includes instructions for filing rights related to unemployment insurance benefits.

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Where to send form 5020?

Forward the original copy of the Form 5020, the accident investigation forms and the completed and signed DWC1 to WCD at 700 East Temple Street, Room 210, Los Angeles, CA 90012, Mail Stop 391, by fax at (213) 473-3333, or via email at per.wcdiv@lacity.org.

Who submits the CA 16 form?

If an employee requires medical treatment for a traumatic injury, a supervisor should complete the front of Form CA-16, within four hours of request whenever possible; however, if the supervisor doubts whether employees condition is related to employment, they should not issue Form CA-16.

What is the first report of injury form in NJ?

Form 1A-1 First Report of Injury (FROI). As soon as you have been notified of a work-related injury, please fill out this form and submit it to EMPLOYERS. This form must be completed within three days from notice of a work-related injury. Fatalities must be reported within 24 hours.

Who fills out the 5020 form?

The Employers Report of Occupational Injury or Illness (Form 5020). Every employer is required to file a complete report of every occupational injury or illness to each employee which results in lost time beyond the date of injury or illness or which requires medical treatment beyond first aid*.

Who fills out a CA 7 form?

Form CA-7 should be submitted by an injured worker (IW) every two weeks while disabled and in a LWOP status, unless the IW has been placed on the periodic roll.

Who fills out proof of employment?

Both employees and employers (or authorized representatives of the employer) must complete the form. On the form, an employee must attest to their employment authorization. The employee must also present their employer with acceptable documents as evidence of identity and employment authorization.

How long do you have to report a work injury in NJ?

The employee must notify the employer of their accident and injury no later than ninety days from the date or discovery of the injury. Failure to meet the deadline results in the injure employee being barred from receiving any workers compensation benefits.

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.

State of new jersey employers first report of accidental injury or occupational illness form 2025

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