Get Office Use Only C-2f Oswego County Self-insurance Plan ...

Filling out the OFFICE USE ONLY C-2F OSWEGO COUNTY SELF-INSURANCE PLAN form is an important step in reporting work-related injuries or illnesses. This guide offers comprehensive instructions to assist users in completing the form accurately and efficiently online.

Follow the steps to successfully fill out the form:

1. Click the ‘Get Form’ button to obtain the form and open it in your editing interface.
2. Begin by selecting the appropriate category for the information being reported: Information Only, Medical Only, or Lost Time greater than 7 days.
3. Enter the Claim Number in the designated field.
4. Complete the EMPLOYER'S FIRST REPORT OF WORK-RELATED INJURY/ILLNESS section by filling in the Employee Name, Time of Injury, Date of Injury, and Time Work/Shift Started.
5. Provide accurate INSURER/CLAIM ADMINISTRATOR INFORMATION, including the Insurer Name and address.
6. Fill in the EMPLOYEE INFORMATION section with the employee’s details such as First Name, Last Name, Mailing Address, Phone Number, Date of Hire, Date of Birth, Gender, and Email Address.
7. Complete the CLAIM INFORMATION section, indicating the relevant dates and employment status, along with estimated weekly wage.
8. In the INJURY INFORMATION section, provide details about the nature of the injury, initial treatment, and any necessary medical provider information.
9. Specify the severity of the injury by selecting the appropriate checkboxes under ‘HOW SERIOUS WAS THE INJURY?’ and complete the WORK STATUS section if applicable.
10. Fill in the ACCIDENT LOCATION AND WITNESSES section with the details of where the incident occurred, including witness information.
11. Complete the EMPLOYER INFORMATION section with the relevant department and address details.
12. In the INSURED INFORMATION section, input the FEIN, Insured Name, and other policy details.
13. Finally, review the form for accuracy before entering the date and signature of the person preparing the form.
14. Save any changes, and download, print, or share the form as necessary.

Start completing the OFFICE USE ONLY C-2F OSWEGO COUNTY SELF-INSURANCE PLAN online today.