Get Form 101 (first Report Of Injury) - Atlantic Charter Insurance Company

Filling out the Form 101 (First Report Of Injury) is an important step in reporting workplace injuries. This comprehensive guide will walk you through each section of the form, ensuring you understand what information is required and how to provide it effectively when completing the form online.

Follow the steps to fill out the Form 101 online successfully.

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. Begin by entering the employee’s name (last, first, middle initial) in the first field.
3. Input the home telephone number of the employee in the specified field.
4. Provide the complete home address, including number, street, city, state, and zip code.
5. Fill in the employee’s social security number; note that disclosure is voluntary but recommended for processing.
6. Select the native language code if applicable, indicating the preferred language of the employee.
7. Indicate the employee’s marital status by selecting from the options provided.
8. Enter the number of dependents the employee has.
9. Input the employee’s date of birth in the required format (mm/dd/yyyy).
10. Record the date of hire for the employee.
11. Specify the sex of the employee by marking the appropriate box.
12. Indicate the employee’s average weekly wage; specify whether this is an estimated or actual figure.
13. Enter the employer’s name as it appears on official records.
14. Provide the employer’s federal tax identification number.
15. Fill out the employer’s address in full detail.
16. Input the employer’s telephone number.
17. Select the appropriate industry code from the options provided.
18. Provide the name and contact number of the workers’ compensation insurance carrier.
19. Fill in the workers’ compensation policy number.
20. Indicate whether the employer is self-insured, and if so, provide the self-insurer number.
21. Specify the business type by selecting the appropriate category.
22. Record the date of the injury in the format (mm/dd/yyyy).
23. State whether the injury occurred on the employer’s premises.
24. If the injury occurred off-premises, provide the location of the injury.
25. Enter the first day of total or partial incapacity to earn wages.
26. Input the fifth day of total or partial incapacity.
27. If applicable, provide the date of death of the employee if the injury resulted in fatality.
28. Specify the source of the injury, such as chemicals or machinery.
29. Briefly describe how the injury or exposure occurred, including the body parts involved.
30. Enter the name and position of the person to whom the injury was reported.
31. Input the date the injury was reported to the employer.
32. Fill in injury codes and body part codes based on the description provided.
33. List any witnesses to the injury by providing their full names.
34. Indicate if the employee has returned to work and, if so, provide the date.
35. Fill in the employee’s regular occupation.
36. State whether the employee has returned to their regular occupation.
37. Complete the preparer’s name, title, and signature.
38. Enter the date the form was prepared.
39. Make sure to save any changes made, and before final submission, review the information for accuracy.
40. Once completed, users can download, print, or share the form for submission.

Start filling out the Form 101 online to ensure timely reporting of workplace injuries.