Get Workers Compensation First Report Of Injury Or Illness

Successfully completing the Workers Compensation First Report of Injury or Illness is crucial for timely processing of claims. This guide will walk you through the necessary steps to accurately fill out the form online.

Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online document editor.
2. Enter the employer's name and address, including ZIP code, in the designated fields. Ensure all information is accurate and current.
3. Input the carrier or administrator claim number. If applicable, also include the OSHA log number and purpose code.
4. Specify the jurisdiction and jurisdiction claim number if assigned. Include your employer's Federal Employer Identification Number (FEIN) and contact number.
5. Fill in employee details: name, date of birth, social security number, date hired, address, sex, marital status, occupation, and employment status.
6. Provide the necessary information regarding the employee's wage, including the number of days worked per week and weekly wage rate.
7. Document the date of injury or illness, time of occurrence, and any significant details related to the event that caused the injury.
8. Detail the type and part of body affected by the injury or illness. Include a description of what the employee was doing at the time of the incident.
9. Indicate whether the injury or illness occurred on the employer's premises and describe any relevant equipment, materials, or chemical exposure involved.
10. Explain the sequence of events leading to the injury or illness, including any contributing factors or equipment involved.
11. Complete the section pertaining to medical treatment, specifying if it was provided, the name and address of the healthcare provider, and the nature of the treatment.
12. Review all information for accuracy and completeness before proceeding to save your changes or download, print, or share the completed form.

Ensure you complete and submit your Workers Compensation First Report of Injury or Illness online for efficient processing.