Get the free Employer’s First Report of Occupational Injury or Illness

This document is a report for employers in Connecticut to file regarding an employee's occupational injury or illness that results in incapacity for one day or more. It captures essential details

How to fill out employers first report of

How to fill out Employer’s First Report of Occupational Injury or Illness

1. Obtain the Employer’s First Report of Occupational Injury or Illness form from your state's workers' compensation board or agency.
2. Complete the employer information section including the name, address, and contact information of the employer.
3. Fill in the employee's personal details such as name, address, date of birth, and job title.
4. Provide details regarding the injury or illness, including the date and time it occurred, the location, and a description of how it happened.
5. Include information on any witnesses present at the time of the incident.
6. Document any medical treatment the employee has received or will receive and the name of the treating physician, if known.
7. Sign and date the report, then submit it to the appropriate workers' compensation insurance carrier and relevant state agency, usually within a specified timeframe.

Who needs Employer’s First Report of Occupational Injury or Illness?

1. Employers who have employees that experience work-related injuries or illnesses.
2. Insurance companies handling workers' compensation claims.
3. State workers' compensation boards that regulate and track workplace injuries and illnesses.
4. HR departments or safety officers who manage workplace safety and employee records.

People Also Ask about

What is the first thing a supervisor should do when an injury is reported?

Report the injury to your employer by telling your supervisor right away. If your injury or illness developed over time, report it as soon as you learn or believe it was caused by your job. Reporting promptly helps prevent problems and delays in receiving benefits, including medical care you may need.

What is the first report of loss?

What to include in a work incident report The date and time of the incident. The name of the witness or author of the report. A detailed description of the events. The names of the affected parties. Other witness statements or important information. The result of the incident.

What is a DWC 1 form used for?

Normally the first step in the formal claims process, the first notice of loss (FONL) is the initial report made to an insurance provider following loss, theft, or damage of an insured asset. Taking this step is key to getting reimbursed for costs that your insurance covers.

Which should be the first response if there is an injury on the job?

As an employer, you are responsible for avoiding workplace injuries by providing your employees with a safe place to work. After an employee injury, you must complete a First Report of Injury and forward it to your workers' compensation carrier.

What is a first report of injury form?

The Employer's 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 claimant's employment and circumstances surrounding the injury or illness are also requested.

For pdfFiller’s FAQs

What is Employer’s First Report of Occupational Injury or Illness?

The Employer's First Report of Occupational Injury or Illness is a document that employers are required to file with their workers' compensation insurance provider, detailing incidents of occupational injuries or illnesses that occur to employees while they are at work.

Who is required to file Employer’s First Report of Occupational Injury or Illness?

Employers who have employees that sustain an injury or illness in the course of their employment are required to file the Employer's First Report of Occupational Injury or Illness.

How to fill out Employer’s First Report of Occupational Injury or Illness?

To fill out the Employer's First Report of Occupational Injury or Illness, employers should gather relevant information about the incident, such as employee details, the nature of the injury or illness, the circumstances surrounding the incident, and any medical treatment that was provided, and then complete the form accurately before submitting it to their insurance provider.

What is the purpose of Employer’s First Report of Occupational Injury or Illness?

The purpose of the Employer's First Report of Occupational Injury or Illness is to notify the workers' compensation insurer of the injury or illness, initiate the claims process, and ensure that affected employees receive the necessary medical care and benefits.

What information must be reported on Employer’s First Report of Occupational Injury or Illness?

The information that must be reported on the Employer's First Report of Occupational Injury or Illness includes the employee's name and contact information, the date and time of the injury or illness, a description of what happened, the location of the incident, the nature of the injury or illness, and details about any medical treatment received.