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EMPLOYERS FIRST REPORT OF INJURY OR ILLNESSForm 122ERev 10×2019TO BE COMPLETED BY EMPLOYER WITH ORIGINAL SENT TO INSURANCE CARRIER AND COPY SENT TO INJURED WORKERINJURED WORKER INFORMATION: Name:Phone:Address:City:Social
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01
Open the PDF employers first report form.
02
Fill out personal information such as your name, address, and contact details.
03
Provide information about your employer, including their name, address, and contact details.
04
Specify the date and time of the incident or injury.
05
Describe the accident or injury in detail, including how it occurred and what body parts were affected.
06
Include information about any witnesses to the incident.
07
Provide details about any medical treatment received, including the name of the healthcare provider and any medications prescribed.
08
Attach any supporting documentation, such as medical records or witness statements.
09
Review the completed form for accuracy and completeness.
10
Sign and date the form.
11
Submit the filled out form to the appropriate party, such as your employer or insurance company.

Who needs pdf employers first report?

01
The PDF employers first report is needed by employees who have experienced a work-related injury or illness. It is important for them to complete this report in order to document the incident and initiate any necessary workers' compensation claims or insurance processes.
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The pdf employers first report is a form that employers use to report their employees' first time working for the company.
All employers are required to file the pdf employers first report for each new employee.
The pdf employers first report must be filled out with the employee's personal information, start date, position, and any other relevant details.
The purpose of the pdf employers first report is to keep track of new employees and ensure compliance with labor laws.
The pdf employers first report must include the employee's full name, social security number, address, date of birth, and start date.
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