Get Work Comp First Report Of Injury Form - White Earth Nation

Completing the Work Comp First Report Of Injury Form is essential for documenting workplace injuries or occupational illnesses. This guide provides clear steps to help you fill out the form correctly and efficiently online.

Follow the steps to complete the form accurately and submit it online.

1. Click ‘Get Form’ button to access the Work Comp First Report Of Injury Form and open it in your editor.
2. Begin by entering the employee’s Social Security Number at the top of the form. This information is essential for identifying the claim.
3. Provide the date of the claimed injury or initial diagnosis of the claimed occupational illness. It is important to be as precise as possible.
4. Input the employee’s full name, including last, first, and middle names. This ensures the report is linked to the correct individual.
5. Enter the employee’s phone number, including the area code, to facilitate communication regarding the claim.
6. Indicate the employee's sex and marital status by selecting the appropriate options provided on the form.
7. Fill in the employee’s address, including street, city, state, and zip code. This gives a complete account of the employee’s location.
8. State the employee’s date of birth, job title, and employment status (full time, part time, etc.). This helps in understanding their work classification.
9. Record the class code, date of hire, and average gross weekly wage. This information supports the compensation assessment.
10. Respond to questions about lost time from work due to the claimed injury, including the first day of lost time and whether the employee has returned to work.
11. Document the employer’s details, including their name, title, phone number, and address, to support the claim's verification.
12. Specify the location where the injury occurred and provide details about the nature of the injury, including part of the body affected and the type of accident.
13. If applicable, complete the section regarding any fatal outcomes from the injury, including the next-of-kin's information.
14. Finally, sign and date the document to validate the information provided. After filling out all sections, save your changes.
15. You may choose to download, print, or share the completed form as needed for your records or submission.

Start completing your Work Comp First Report Of Injury Form online today for efficient processing.