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IA1 WORKERS COMPENSATION FIRST REPORT OF INJURY OR ILLNESS General Employer (Name & Address incl. zip) Carrier/Administrator Claim Number Republic Diesel, Inc. P O Box 35650 Louisville, KY 402325650

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How to fill out workers compensation first report

01

Gather all relevant information about the injured worker, including their name, address, and contact details.

02

Collect details about the injury, such as the date, time, and location it occurred.

03

Provide a description of the injury, including the body part affected and the nature of the injury.

04

Include information about any witnesses present at the time of the incident.

05

Fill out the employer's section of the first report, providing details about the company and its workers' compensation insurance coverage.

06

Include any additional information required by your state's workers' compensation board.

07

Submit the completed first report to the appropriate workers' compensation board within the specified timeframe.

08

Keep a copy of the first report for your records.

Who needs workers compensation first report?

01

Employers are required by law to fill out the workers' compensation first report in case of an employee's work-related injury or illness.

02

Workers who experience a work-related injury or illness should also ensure that their employer fills out the first report to initiate the workers' compensation claim process.

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What is workers compensation first report?

Workers compensation first report is a document that must be filed by employers or their insurance carriers when an employee suffers a work-related injury or illness.

Who is required to file workers compensation first report?

Employers or their insurance carriers are required to file workers compensation first report.

How to fill out workers compensation first report?

Workers compensation first report can be filled out by providing information about the injured employee, details of the injury or illness, and any treatment received.

What is the purpose of workers compensation first report?

The purpose of workers compensation first report is to document work-related injuries or illnesses, ensure that the employee receives appropriate medical treatment, and determine eligibility for workers compensation benefits.

What information must be reported on workers compensation first report?

The information that must be reported on workers compensation first report includes details of the employee, date and time of injury, description of the injury or illness, and any treatment received.

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