Follow the steps to accurately complete the report.

1. Click ‘Get Form’ button to access the EMPLOYER'S BASIC REPORT OF INJURY and open it for editing.
2. Begin with the employee data section, entering the employee's social security number, date of injury, full name, address, date of birth, sex, number of dependents, and contact number. Ensure accuracy in each of these fields.
3. Proceed to the employer/carrier data section. Fill in the employer's name, federal ID number, injury location code, mailing location code, street address, UI number, business type, city, state, zip code, insurance company name, and insurance company telephone number. This data must reflect the employer's information precisely.
4. In the injury/medical data section, detail the last day worked, the date the employee returned to work (if applicable), and whether the employee died as a result of the injury. Also, indicate the injury city, state, and county, and specify whether the incident occurred on the employer's premises.
5. Describe the circumstances of the injury, including what the employee was doing right before the incident, how the injury occurred, the nature of the injury, and the specific part of the body affected. List any objects or substances that caused harm, as well as the name of the healthcare professional who treated the employee.
6. Complete the occupation and wage data section by entering the date hired, total gross weekly wage, number of weeks used for the statistic, and specific occupation of the employee. Confirm whether the employee was a volunteer or certified as vocally handicapped.
7. Fill out the preparer data section by providing your name, signature, contact number, and date prepared. This section certifies that a copy of the report has been provided to the employee.
8. After reviewing all entries for accuracy, save the changes made to the form. You may also download, print, or share the completed report as needed.

Complete your reports online today to ensure compliance and provide necessary documentation.