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Employer's First Report of Work-Related Injury Worksheet Per Section 110 of the Workers' Compensation Law a work-related injury or illness must be reported within 10 days of notice of the injury or
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How to fill out first report of injury

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How to fill out the first report of injury:

01
Begin by providing your personal information, such as your name, address, phone number, and email address. Make sure to include the date and time the injury occurred.
02
Describe the details of the injury. Include the location of the incident, what caused the injury, and any contributing factors. Be as specific as possible to provide a clear picture of the situation.
03
Note any witnesses to the incident. Include their names and contact information, as their testimony may be valuable for future investigations or claims.
04
Indicate whether medical attention was sought for the injury. If so, provide details about the medical facility or doctor visited, as well as any treatments or medications received.
05
If applicable, include information about any previous or related injuries. This can help identify patterns or potential underlying causes.
06
Explain the impact the injury has had on your daily life. Describe any pain, limitations, or difficulties you have experienced as a result of the injury. This can be important for assessing the severity and long-term effects of the incident.
07
Sign and date the first report of injury form to certify the accuracy of the information provided.

Who needs the first report of injury?

The first report of injury is typically required by employers or insurance companies. It serves as a formal record of the injury and is used to initiate the workers' compensation process. It may be requested by the employer's human resources department, health and safety personnel, or the insurance claims department. The information provided in the report helps determine the validity of the claim and can assist in arranging appropriate medical treatment and compensation for the injured person.
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The first report of injury is a form that is used to report workplace injuries or illnesses to the appropriate authorities.
Employers are required to file the first report of injury when an employee sustains a work-related injury or illness.
The first report of injury can typically be filled out online or submitted through a paper form provided by the employer or the workers' compensation insurance carrier.
The purpose of the first report of injury is to document and track workplace injuries or illnesses, ensure that the employee receives appropriate medical treatment, and initiate the workers' compensation claim process.
Information that must be reported on the first report of injury includes details of the injury or illness, the date and time it occurred, the location where it occurred, and the names of the individuals involved.
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