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Workers Compensation FIRST REPORT OF INJURY OR ILLNESSJurisdiction Code Jurisdiction Claim Number CLAIM ADMIN Claim Administrator Name: Catholic Mutual Proclaim Representative Business Phone Number:
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How to fill out workers compensation first report

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How to fill out workers compensation first report

01
Obtain the necessary forms from your employer or workers' compensation insurance carrier.
02
Gather all relevant information about the injured worker, including their name, address, social security number, and job title.
03
Document the date, time, and location of the injury.
04
Obtain details about how the injury occurred and any witnesses present.
05
Provide a detailed description of the injury, including the body parts affected and the extent of the injury.
06
Include any medical treatment received by the injured worker, including the name of the healthcare provider and any medications prescribed.
07
Fill out the wage information section, including the injured worker's average weekly wage and any time missed from work due to the injury.
08
Sign and date the form, and make a copy for your records before submitting it to the appropriate party.

Who needs workers compensation first report?

01
Employers who have employees covered by workers' compensation insurance need to fill out the workers' compensation first report. This report is usually required when an employee suffers a work-related injury or illness and wants to file a claim for workers' compensation benefits.

What is Workers Compensation FIRST REPORT OF INJURY OR ILLNESSJurisdiction Code Jurisdiction Claim Number Form?

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Workers compensation first report is a form that must be filed by an employer when an employee has been injured on the job.
Employers are required to file workers compensation first report when an employee is injured on the job.
To fill out workers compensation first report, employers must provide details about the employee, the injury, and how it occurred.
The purpose of workers compensation first report is to document and report workplace injuries in order to ensure that employees receive proper medical treatment and compensation.
Information that must be reported on workers compensation first report includes details about the employee, the injury, the date and time of the incident, and any witnesses.
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