Get the free First report of injury form WKC-12 2 - Wisconsin

EMPLOYERS FIRST REPORT OF INJURY OR DISEASE Department of Workforce Development Workers Compensation Division 201 E. Washington Ave., Rm. C100 Fatal Injuries: Employers subject to ch.102, Wis. Stats.,

How to fill out first report of injury

How to fill out the first report of injury:

1. Gather all necessary information: Start by collecting all relevant details about the injured individual, including their name, contact information, job title, and department. Also, gather information about the nature of the injury, location, date, and time it occurred.
2. Describe the injury incident: Provide a clear and concise description of how the injury happened. Include specific details such as the events leading up to the incident, any equipment involved, and any contributing factors.
3. Record witness statements: If there were any witnesses to the injury incident, gather their statements. Include their names, contact information, and a detailed account of what they observed.
4. Complete the worker's information section: Fill out the injured worker's information section accurately. Include their personal details, job classification, start date, and wage rate. Also, mention any prior injuries or medical conditions that may be relevant.
5. Document medical treatment: Include information about the medical treatment the injured individual received. Record the name and contact information of the healthcare provider, as well as any diagnoses, prescribed medications, and future treatment recommendations.
6. List lost work time: Indicate the date the injured worker started missing work and the expected duration of absence. Additionally, document any lost wages or other financial impacts resulting from the injury.
7. Submit the report: Once you have completed all the necessary sections, review the report for accuracy and completeness. Sign and date the form, then submit it according to the established process in your organization.

Who needs the first report of injury:

1. Employers: The employer or their designated representative must have a copy of the first report of injury to initiate the workers' compensation process. This report helps them manage and document workplace injuries appropriately.
2. Injured workers: The injured worker is also required to have a copy of the first report of injury for their records. It serves as a documentation of the incident, medical treatment received, and any possible future claims related to the injury.
3. Insurance providers: Insurance companies or third-party administrators responsible for workers' compensation claims need the first report of injury to initiate the claim process. It allows them to assess the claim, determine liability, and provide appropriate compensation if required.
4. Regulatory authorities: Depending on the jurisdiction, regulatory authorities, such as state labor departments, may require the first report of injury to ensure compliance with workers' compensation laws and regulations. Providing this report allows them to monitor workplace safety and manage any potential violations or hazards.

For pdfFiller’s FAQs

What is first report of injury?

First report of injury is a form that documents the details surrounding a work-related injury or illness.

Who is required to file first report of injury?

Employers are typically responsible for filing the first report of injury.

How to fill out first report of injury?

The first report of injury should be filled out completely and accurately, detailing the incident, injuries, and other relevant information.

What is the purpose of first report of injury?

The purpose of the first report of injury is to document work-related injuries or illnesses, track trends, and ensure appropriate care and compensation for injured employees.

What information must be reported on first report of injury?

Information such as the date, time, location of the incident, nature of injury, and details of the affected employee must be reported on the first report of injury.

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