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

1. Click ‘Get Form’ to open it in the editor.
2. 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.
3. 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.
4. 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.
5. 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.
6. Describe the accident by detailing where it occurred and what the employee was doing at that time. Be specific to ensure clarity.
7. 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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