Get Employers Report Of Work Related Injuryillness C 2 Form

The Employers Report Of Work Related Injury/Illness C 2 Form is essential for documenting workplace injuries or illnesses. Completing this form accurately and promptly is crucial to ensure compliance with reporting requirements and to facilitate the necessary claims process.

Follow the steps to effectively complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill out the required fields in Section A, Employer Information. Enter the employer's name, Federal Employer Identification Number (FEIN), phone number, and mailing address including city, state, country, and zip code.
3. In Section B, provide information regarding the insurance carrier or, if applicable, the self-insured employer. Complete the Board W Number, carrier/group name, policy number, and insurance agent contact details if needed.
4. Proceed to Section C to input the employee's personal information. This includes the employee's first name, last name, date of birth, social security number, and mailing address details.
5. In Section D, describe the circumstances of the employee's injury or illness. Fill in details such as the time of injury, whether the employee provided notice, the location of the incident, and specifics about what the employee was doing at the time.
6. Continue to Section E to indicate if the employee received medical treatment and if they had any other work-related injuries to the same body part.
7. In Section F, answer questions regarding the employee's work status after the injury or illness, including whether they stopped working and if they have returned.
8. Complete Section G by detailing the employee's job information at the time of the incident, including their hiring date and job title.
9. Fill out Section H with the employee’s payroll information, confirming average weekly gross pay, whether lodging or tips were received, and work schedule details.
10. Review any additional information required in Section I, affirming that the information provided is accurate. Check the appropriate boxes based on who prepared the report.
11. After ensuring all required fields are completed, select the 'Save Data' button if you wish to keep a copy of the entered information. Alternatively, you can submit the form directly.
12. Finally, do not close your web browser until you receive a confirmation confirming that the Board has received your form.

Ensure your compliance by completing the Employers Report Of Work Related Injury/Illness C 2 Form online promptly and accurately.