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WORKER S COMPENSATION FIRST REPORT OF INJURY OR ILLNESS Employer Name Carrier/Administration Claim Number Street Address Jurisdiction City G E N E R A L Injured Report Number State ZIP Code SIC Code

How to fill out worker39s compensation first report

How to Fill out Worker's Compensation First Report:

1. Obtain the necessary forms: Start by obtaining the Worker's Compensation First Report form from your employer or the relevant workers' compensation agency. Make sure to also gather any other documentation or evidence related to the injury or incident.
2. Provide personal and employer information: Begin by filling out your personal details, such as your name, address, contact information, and social security number. Then, provide the relevant information about your employer, including their name, address, and contact details.
3. Describe the injury or incident: Next, provide a detailed account of how the injury or incident occurred. Describe the events leading up to the incident, the specific actions that caused the injury, and any witnesses present. Be as precise and accurate as possible to ensure a thorough report.
4. Include medical information: Document any medical treatment or evaluation you received as a result of the injury. This may include visits to doctors, hospitals, or clinics, as well as any prescribed medications or recommended therapies. Attach any supporting medical records or bills to the report if requested.
5. Provide information about lost wages: If the injury has caused you to miss work or resulted in reduced income, include details about lost wages in the report. Specify the dates of absence, the number of hours missed, and any impact on your overall earning capacity.
6. Sign and submit the report: Once you have completed all the necessary sections of the Worker's Compensation First Report form, review it for accuracy, and sign it. Keep a copy of the report for your records, and submit the original to your employer or the designated workers' compensation agency within the specified timeframe.

Who Needs Worker's Compensation First Report:

1. Employers: Employers need the Worker's Compensation First Report to initiate the claims process and provide necessary documentation for their records. It helps them comply with legal requirements and determine the validity of the reported incident.
2. Employees: Employees who have suffered a work-related injury or illness need to complete the Worker's Compensation First Report to initiate the claims process. It serves as an official record of the incident and ensures that the employee receives the necessary benefits and medical treatment.
3. Workers' Compensation Agencies: Workers' compensation agencies require the Worker's Compensation First Report to assess the validity of a claim and determine the appropriate benefits for the injured employee. It helps them manage the claims process effectively and protect the rights of both employers and employees.

For pdfFiller’s FAQs

What is worker39s compensation first report?

Worker's compensation first report is the initial report submitted to the employer's insurance carrier when an employee suffers a work-related injury or illness.

Who is required to file worker39s compensation first report?

The employer or their designated representative is required to file the worker's compensation first report.

How to fill out worker39s compensation first report?

The worker's compensation first report can be filled out by providing details of the employee, the injury or illness, the date/time/location of the incident, and any other relevant information.

What is the purpose of worker39s compensation first report?

The purpose of the worker's compensation first report is to initiate the process of providing benefits to employees who are injured or become ill due to their work.

What information must be reported on worker39s compensation first report?

The worker's compensation first report must include details about the employee, the nature of the injury/illness, the date/time/location of the incident, and any medical treatment received.

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