Get First Report Of Injury - Pennsylvania - Icw Group

Filling out the First Report Of Injury form is a vital step in reporting workplace injuries in Pennsylvania. This guide provides comprehensive steps to help you complete the form accurately and efficiently online.

Follow the steps to fill out the First Report Of Injury form successfully:

1. Click ‘Get Form’ button to access the First Report Of Injury form and open it in the online editor.
2. Enter the employee information, including their first name, last name, employee ID, date of birth, and middle name if applicable. Ensure that all details are accurate.
3. Fill in the mailing address for the employee, including the city, state code, postal code, and country code. Confirm that the contact information is up to date.
4. Provide the employee's marital status, number of dependents, and occupation description in the respective fields.
5. In the claim information section, enter the jurisdiction claim number, initial date when the disability began, type of loss, and initial return to work date, if applicable.
6. Complete the injury information section by stating the date of injury, time of injury, nature of injury, part of body injured, cause of injury, and a detailed narrative describing the accident or injury.
7. If applicable, provide denial information, including any relevant codes and narratives related to the claim.
8. Fill in the insurer information, ensuring to include the insurer's name, FEIN, and insured report number.
9. Detail claim administrator information like name, FEIN, postal code, and claim administrator's address.
10. Complete the employer information section, including the company's name, primary address, contact name, and phone number.
11. After filling out all sections of the form, review the information for accuracy. Once confirmed, you can save your changes, download the form, print it, or share it as necessary.

Complete your documents online today to ensure timely reporting of workplace injuries.