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Employer's First Report of Injury or Occupational Illness (See instructions on reverse - Leave Items 1 and 2 blank) Print Reset Submit 2. Carrier's No. 1. OWCP No. Employment Standards Administration.

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DWC1 First Report of Injury (FROI). As soon as you have been notified of a work-related injury, please fill out this form and submit it to EMPLOYERS. This form must be completed within 10 days from notice of a work-related injury. Fatalities must be reported within 24 hours.

Your employer should report the injury as soon as possible, but no later than seven (7) days after their knowledge. The insurance company must send you an informational brochure within three (3) days after receiving notice from your employer.

The employer is required to file an Employer's First Report of Injury or Illness [DWC FORM-001 Rev. 10/05] with the injured worker's insurance carrier, and the injured claimant or the claimant's representative within 8 days after the employee's absence from work or receipt of notice of occupational disease.

If you get hurt on the job, your employer is required by law to pay for workers' compensation benefits. You could get hurt by: One event at work. Examples: hurting your back in a fall, getting burned by a chemical that splashes on your skin, getting hurt in a car accident while making deliveries.

The register of injuries must include: the name of the injured worker. the worker's address. the worker's age at the time of injury. the worker's occupation at the time of injury. the industry in which the worker was engaged at the time of injury. the time and date of injury. the nature of the injury. the cause of the injury.

Typically an injured employee is required to provide written notice, and most states set deadlines for reporting injuries.

Reporting promptly helps avoid problems and delays in receiving benefits, including medical care. If you don't report your injury within 30 days, you could lose your right to receive workers' compensation benefits.

Typically, if your employer is assisting you with the claims process, and you are advised to file an LS-203 form, called an “Employee's Claim for Compensation,” then you are likely filing a Defense Base Act claim.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232