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WORKERS COMPENSATION FIRST REPORT OF INJURY OR ILLNESS EMPLOYER (NAME & ADDRESS INCL ZIP) CARRIER/ADMINISTRATOR CLAIM NUMBER JURISDICTION South Side Mission P.O. Box 5579 Peoria IL 61601 OSHA LOG

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How to fill out workers compensation first report

01

Step 1: Gather all necessary information about the workplace accident, including the date, time, and location.

02

Step 2: Identify the injured worker by collecting their personal details such as name, contact information, and employee identification number.

03

Step 3: Document the nature and extent of the worker's injuries, and any medical treatment received or required.

04

Step 4: Fill out the cause and description of the accident, including any contributing factors or unsafe conditions that may have led to the incident.

05

Step 5: Provide information about the employer, including their name, address, and contact details.

06

Step 6: Include details about witnesses, if any, who can provide additional information or statements regarding the accident.

07

Step 7: Sign and date the workers compensation first report, ensuring it is submitted within the required timeframe.

08

Step 8: Keep a copy of the completed report for your records and submit it to the appropriate workers compensation authority or insurance provider.

Who needs workers compensation first report?

01

Employers: Employers are required by law to provide workers compensation coverage for their employees. They need to file a workers compensation first report in case of workplace accidents.

02

Injured Employees: Employees who have been injured on the job and seek compensation benefits must fill out a workers compensation first report.

03

Medical Providers: Medical providers may also need to complete a workers compensation first report to document the injuries, treatments, and services provided to the injured worker.

04

Insurance Providers: Insurance providers use the workers compensation first report to process claims and determine the appropriate benefits to be provided to the injured worker.

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What is workers compensation first report?

Workers compensation first report is a form that must be filled out by employers when an employee is injured on the job.

Who is required to file workers compensation first report?

Employers are required to file the workers compensation first report.

How to fill out workers compensation first report?

The form can typically be filled out online or submitted to the appropriate state agency.

What is the purpose of workers compensation first report?

The purpose of the report is to document the details of the injury and ensure that the injured worker receives the appropriate benefits.

What information must be reported on workers compensation first report?

The report typically requires information about the injured employee, the injury itself, and the circumstances surrounding the injury.

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