Get Indiana Worker's Compensation First Report Of ...

Filling out the Indiana Worker's Compensation First Report of Employee Injury, Illness is essential for reporting workplace incidents accurately and promptly. This guide will walk you through each section of the form, ensuring you understand the requirements and can complete it effectively.

Follow the steps to accurately complete the form.

1. Press the ‘Get Form’ button to acquire the form and open it in the editor.
2. Begin by entering the jurisdiction claim number and process date in the designated fields. Ensure these details are accurate as they are crucial for tracking the claim.
3. Fill out the employee information section. Include the employee's Social Security number, date of birth, name, and occupation or job title. Also, provide details like the date hired, employee status, and marital status.
4. In the wage section, indicate the average weekly wage, hours worked per day, and days worked per week. Remember to fill in the details for dependents if applicable.
5. Proceed to the employer information segment. Enter the employer's name, ID number, and address. Ensure the telephone number is accurate for contacting purposes.
6. Continue with the carrier or claims administrator information. Provide the name and address of the claims administrator and check if self-insured. Fill in all relevant identification numbers.
7. Document the occurrence or treatment information. This includes the date and time of the injury, type of injury or exposure, and part of the body affected. If applicable, also note any witnesses or medical treatment received.
8. Finally, review all entries for accuracy. Once confirmed, save your changes, and then download, print, or share the completed form through the provided options.

Now that you have the guidance, complete your INDIANA WORKER'S COMPENSATION FIRST REPORT online with confidence.