Get the free First Report of Injury Form - City of Duluth - duluthmn

Reset Minnesota Department of Labor and Industry Workers Compensation Division PO Box 64221 St. Paul, MN 55164-0221 (651) 284-5030 First Report of Injury See Instructions on Reverse Side PRINT IN

How to fill out first report of injury

How to Fill Out First Report of Injury:

1. Obtain the necessary forms: Begin by obtaining the specific first report of injury form required by your employer or insurance company. This form is typically available from your human resources department or can be downloaded from the company's website.
2. Identify the injured party: Fill in the injured employee's information, including their full name, contact details, and employment details. Ensure accuracy as this information is crucial for identification.
3. Describe the incident: Provide a detailed account of how the injury occurred. Include the date, time, and location of the incident. Additionally, describe the specific tasks the employee was performing when the injury happened.
4. Document witness statements: Record any statements from witnesses who saw the incident take place. Include their names, contact information, and a brief summary of what they observed. Witness statements can provide valuable information for the claims process.
5. Specify the extent of the injury: Indicate the type and severity of the injury sustained by the employee. If multiple injuries occurred, list them individually. Include details such as body parts affected and specific symptoms experienced.
6. Record medical treatment: Describe the medical treatment provided to the injured employee promptly following the incident. This includes any emergency room visits, consultations with healthcare professionals, medication prescribed, or further medical care required.
7. Include details of missed work: Indicate whether the employee was unable to work due to the injury and provide dates for the missed days. Note any loss of wages or potential additional expenses incurred.
8. Submit the form: Once the form is completed, sign and date it. Submit the form according to the established procedures outlined by your employer or insurance company. This may involve sending it to specific individuals or departments within the organization.

Who Needs First Report of Injury:

1. Employers: Employers need the first report of injury to document and report workplace injuries accurately. It helps them understand the details of the incident, evaluate safety protocols, and determine if any corrective actions are required to prevent future injuries.
2. Insurance Companies: Insurance companies require the first report of injury to assess and process the related claims. It helps them determine the liability of the employer and provide appropriate compensation or coverage to the injured employee.
3. Employees: Employees need to fill out the first report of injury as it is their opportunity to communicate the details of the incident and ensure that their rights are protected. It acts as a record of the event and can help support their claims for medical treatment, compensation, or other benefits.

For pdfFiller’s FAQs

What is first report of injury?

The first report of injury is a form used to report any work-related injuries or illnesses.

Who is required to file first report of injury?

Employers are required to file the first report of injury when an employee is injured on the job.

How to fill out first report of injury?

The first report of injury can be filled out online or in paper form, and must include details about the injury, the employee, and the circumstances surrounding the incident.

What is the purpose of first report of injury?

The purpose of the first report of injury is to document work-related injuries and illnesses, track trends, and ensure that employees receive appropriate medical care and compensation.

What information must be reported on first report of injury?

Information such as the date and time of the injury, the nature of the injury, the name and contact information of the employee, and any witnesses to the incident must be reported on the first report of injury.

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