Get the free First Report of Injury - Beacon Mutual Insurance

PLEASE CHECK IF CORRECTION OF PRIOR REPORT EMPLOYER IS FIRST REPORT OF ALLEGED OCCUPATIONAL INJURY, DISEASE, OR FATALITY Insurer File No. 1. EMPLOYER LOCATION: 2. EMPLOYER NAMED ON WC INSURANCE POLICY:

How to fill out first report of injury

How to fill out first report of injury:

1. Obtain the necessary forms: Start by obtaining the official first report of injury form from your employer or workers' compensation insurance provider.
2. Provide personal information: Enter your full name, address, phone number, and social security number in the designated sections of the form.
3. Describe the injury: Clearly explain the details of how the injury occurred, including the date, time, and location of the incident. Describe the specific body parts affected and provide a detailed account of what happened.
4. Include witness information: If there were any witnesses to the injury, provide their names and contact information to support your claim.
5. Document medical treatment: Provide a summary of the medical treatment you received, including the healthcare provider's name and contact information. Include any medications prescribed and whether you required hospitalization or ongoing care.
6. Mention work status: Indicate whether the injury resulted in any missed workdays or if you are currently unable to work due to the injury.
7. Record previous injuries: If you had any previous injuries or health conditions that may be relevant to the current injury, disclose this information.
8. Sign and date the form: Review the completed form carefully, ensuring all information is accurate and complete. Sign and date the form before submitting it to the appropriate party.

Who needs first report of injury:

1. Employers: Employers need the first report of injury to comply with legal requirements and to initiate the workers' compensation claims process. They use the information provided to investigate the incident and determine whether the employee is eligible for benefits.
2. Employees: Employees who suffer a work-related injury or illness need to complete the first report of injury to report the incident to their employer and initiate the workers' compensation process. It ensures that their injury is officially documented and they can receive the necessary medical care and benefits.
3. Workers' compensation insurance providers: These insurance providers require the first report of injury to process and evaluate the claim. The information provided on the form helps determine the extent of the injury, eligibility for benefits, and potential liability for the insurance company.

For pdfFiller’s FAQs

How can I send first report of injury for eSignature?

Once you are ready to share your first report of injury, you can easily send it to others and get the eSigned document back just as quickly. Share your PDF by email, fax, text message, or USPS mail, or notarize it online. You can do all of this without ever leaving your account.

How can I edit first report of injury on a smartphone?

You may do so effortlessly with pdfFiller's iOS and Android apps, which are available in the Apple Store and Google Play Store, respectively. You may also obtain the program from our website: https://edit-pdf-ios-android.pdffiller.com/. Open the application, sign in, and begin editing first report of injury right away.

How do I fill out first report of injury on an Android device?

Use the pdfFiller mobile app to complete your first report of injury on an Android device. The application makes it possible to perform all needed document management manipulations, like adding, editing, and removing text, signing, annotating, and more. All you need is your smartphone and an internet connection.

What is first report of injury?

The first report of injury is a form used by employers to report workplace injuries or illnesses to the appropriate state agency.

Who is required to file first report of injury?

Employers are required to file the first report of injury when an employee is injured or becomes ill due to work-related activities.

How to fill out first report of injury?

The first report of injury form typically requires information about the employee, the injury or illness, and the circumstances surrounding the incident. Employers should provide as much detail as possible.

What is the purpose of first report of injury?

The purpose of the first report of injury is to document workplace injuries and illnesses, track trends in workplace safety, and ensure that employees receive the appropriate medical treatment and benefits.

What information must be reported on first report of injury?

Information that must be reported on the first report of injury includes the employee's name, date of birth, job title, date and time of injury, description of injury, medical treatment received, and any witnesses to the incident.