Get the free First Report of Injury Form - PKT Enterprises

Reset Minnesota Department of Labor and Industry Workers Compensation Division PO Box 64221 St. Paul, MN 55164-0221 (651) 284-5030 First Report of Injury See Instructions on Reverse Side PRINT IN

How to fill out first report of injury

How to fill out a first report of injury:

1. Gather necessary information: Start by collecting all the essential details related to the injury. This includes the date, time, and location of the incident, as well as the name and contact information of the injured person.
2. Describe the injury: Provide a clear and concise description of the injury that occurred. Include information like the nature of the injury, the body part affected, and any other relevant details.
3. Document witnesses: If there were any witnesses present during the incident, make sure to record their names and contact information. Their statements may be crucial for the investigation or insurance purposes.
4. Complete the cause of injury section: Identify the cause or contributing factors that led to the injury. This can include unsafe working conditions, equipment failure, or any other relevant factors.
5. Provide medical treatment details: Record any medical treatment that was administered following the injury. Include the name of the healthcare professional or facility, the type of treatment received, and any medications prescribed.
6. Notify supervisor/employer: Ensure that the first report of injury is promptly submitted to the respective supervisor or employer. This step is crucial for processing workers' compensation claims and initiating further investigation or assistance.

Who needs a first report of injury?

1. Employers: A first report of injury is necessary for employers as it helps them fulfill their legal obligations, track workplace incidents, and initiate the workers' compensation process.
2. Employees: Injured employees need to fill out a first report of injury to ensure they receive the necessary medical treatment, benefits, and compensation for the workplace injury they sustained.
3. Insurance companies: Insurance companies require a first report of injury to assess the claim, determine liability, and provide the appropriate coverage for medical expenses or lost wages.
4. Government agencies: Government agencies often require first reports of injury to monitor workplace safety, identify recurring issues, and ensure compliance with regulations.

Overall, filling out a first report of injury in a timely and accurate manner is crucial for all parties involved. It helps facilitate the necessary steps for medical treatment, claims processing, and ensuring workplace safety.

For pdfFiller’s FAQs

What is first report of injury?

The first report of injury is a form submitted to an employer or workers' compensation insurance company to report an employee's work-related injury or illness.

Who is required to file first report of injury?

Employers are required to file the first report of injury for any work-related injury or illness that occurs to their employees.

How to fill out first report of injury?

The first report of injury can be filled out online or on paper, and it typically requires information such as the employee's name, date of injury, 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 document and track work-related injuries and illnesses, and to ensure that employees receive appropriate medical care 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 injury, description of the injury, date and time of the incident, and any medical treatment received.

When is the deadline to file first report of injury in 2023?

The deadline to file the first report of injury in 2023 is typically within a certain number of days after the injury occurs, but it may vary depending on the specific state or jurisdiction.

What is the penalty for the late filing of first report of injury?

The penalty for the late filing of the first report of injury may vary depending on the specific state or jurisdiction, but it could result in fines or other legal consequences for the employer.

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