Get the free Employer's First Report of Injury Form - Howalt-McDowell Insurance

Clear Form First Report of Injury Minnesota Department of Labor and Industry Workers Compensation Division 443 Lafayette Road North St. Paul, MN 55155-4305 (651) 284-5030 See Instructions on Reverse

How to fill out employer39s first report of

How to fill out Employer's First Report of?

1. Obtain the necessary form: The Employer's First Report of is typically provided by your employer or workers' compensation insurance carrier. If you don't have the form, you may be able to find it on your state's workers' compensation website.
2. Provide your employer's information: Fill in the required fields with your employer's name, address, and contact information. This includes their phone number, email address, and any other relevant details.
3. Add your personal information: Include your own name, address, and contact information. Make sure to provide accurate details to ensure that any updates or communication can be properly delivered to you.
4. Describe the incident: Provide a detailed description of the incident or injury that occurred at work. Include information such as the date, time, and location of the incident, as well as a clear explanation of how you got injured.
5. Include witness information: If there were any witnesses to the incident, provide their names, contact information, and a brief statement about what they observed.
6. Report medical treatment: Indicate whether you sought medical treatment for your injury and provide details of the healthcare provider or facility you visited. Include the date of treatment, what type of treatment was provided, and any medications prescribed.
7. Report missed work: If you had to miss work due to the injury, indicate the dates you were unable to work and any lost wages incurred as a result. Some forms may require additional documentation, such as medical notes or pay stubs, to support your claim.
8. Sign and submit the form: Once you have completed all the necessary sections, sign and date the Employer's First Report of. Keep a copy for your records and submit the original form to your employer's HR department or workers' compensation insurance carrier as instructed.

Who needs the Employer's First Report of?

1. Employers: The Employer's First Report of is required to be filled out by employers as part of their responsibility to report workplace injuries or illnesses to their insurance carrier or state workers' compensation board. It allows them to initiate the workers' compensation claim process and provide necessary information for investigation and coverage determination.
2. Injured employees: If you have suffered a work-related injury or illness, you may need to request your employer to fill out the Employer's First Report of on your behalf. This report helps to initiate the workers' compensation claim process and ensures that your injury is properly documented.
3. Insurance carriers and workers' compensation boards: Insurance carriers and state workers' compensation boards use the Employer's First Report of to gather information about workplace incidents and injuries. This helps them determine whether the incident is eligible for coverage under workers' compensation insurance and aids in resolving any disputes or claims.

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