Get the free First Report of Injury form - Rose-Hulman Institute of Technology - rose-hulman

Indiana Worker's Compensation FOR WORKER'S COMPENSATION BOARD USE ONLY JURISDICTION CLAIM NUMBER First Report of Employee Injury/Illness PROCESS DATE Please Return Completed Form to: 402 W. Washington

How to fill out first report of injury

How to fill out the first report of injury:

1. Start by obtaining the necessary forms from your employer or insurance company. These forms typically include sections to capture details about the injured person, the nature and location of the injury, and any witnesses present at the time of the incident.
2. Fill out the injured person's personal information, such as their full name, address, contact number, and any other applicable details requested on the form.
3. Provide a detailed description of the injury incident, including the date, time, and location of the event. Be as specific and accurate as possible in describing how the injury occurred.
4. If there were any witnesses to the injury, include their names, contact information, and a brief summary of what they saw. Their testimonies can be critical for validating the injury claim.
5. If there were any contributing factors to the injury, such as faulty equipment or hazardous conditions, make sure to document them in the appropriate sections of the form.
6. Provide any necessary medical information related to the injury, such as the name of the healthcare provider who treated the injured person and any medical expenses incurred.
7. Review the completed form for accuracy and completeness before submitting it to the designated recipient, such as your employer's human resources department or your insurance company.

Who needs the first report of injury?

1. Employers typically require the first report of injury to initiate the workers' compensation process and provide immediate medical attention if necessary.
2. The injured person needs the first report of injury to ensure that their rights are protected and that they receive appropriate medical care and compensation.
3. Insurance companies rely on the first report of injury to determine the validity of the claim and assess the need for further investigation or financial compensation.

For pdfFiller’s FAQs

How can I modify first report of injury without leaving Google Drive?

You can quickly improve your document management and form preparation by integrating pdfFiller with Google Docs so that you can create, edit and sign documents directly from your Google Drive. The add-on enables you to transform your first report of injury into a dynamic fillable form that you can manage and eSign from any internet-connected device.

How do I fill out the first report of injury form on my smartphone?

Use the pdfFiller mobile app to complete and sign first report of injury on your mobile device. Visit our web page (https://edit-pdf-ios-android.pdffiller.com/) to learn more about our mobile applications, the capabilities you’ll have access to, and the steps to take to get up and running.

How do I complete first report of injury on an iOS device?

Download and install the pdfFiller iOS app. Then, launch the app and log in or create an account to have access to all of the editing tools of the solution. Upload your first report of injury from your device or cloud storage to open it, or input the document URL. After filling out all of the essential areas in the document and eSigning it (if necessary), you may save it or share it with others.

What is first report of injury?

The first report of injury is a document that provides details about an employee's work-related injury or illness, which is filed with the employer and sometimes also with the workers' compensation board.

Who is required to file first report of injury?

Typically, the employer is required to file the first report of injury, although the injured employee may also be involved in the process, especially in providing necessary information.

How to fill out first report of injury?

To fill out a first report of injury, the employer or designated representative must include details such as the employee's name, job title, date and time of the injury, location of the incident, a description of the injury, and any medical treatment received.

What is the purpose of first report of injury?

The purpose of the first report of injury is to formally document the incident, ensure that the injured employee receives appropriate medical care, and to initiate the process for workers' compensation claims.

What information must be reported on first report of injury?

The information that must be reported includes the employee's name, job title, employer details, date and time of injury, location of the injury, a description of how the injury occurred, and any witness information if applicable.