Get Employer's Report Of Work-related Injury/illness

Filing the Employer's Report of Work-Related Injury/Illness is a crucial step for employers when an employee has sustained a work-related injury or illness. This guide provides step-by-step instructions to ensure you complete this form accurately and efficiently, helping you meet your reporting obligations.

Follow the steps to complete your report online.

1. Click ‘Get Form’ button to access the form and open it in your chosen editor.
2. Begin by filling in the WCB case number if known, along with the date of the injury/illness and the date of your report at the top of the form.
3. Complete Section A: Employer Information. This includes entering your company's name, Federal Employer Identification Number (FEIN), mailing and location addresses, phone number, nature of your business, and any known OSHA case number.
4. Proceed to Section B: Insurance Carrier / Self-Insured Employer. Input the required details such as Carrier Code Number, the name of your insurance carrier, policy number, and the relevant coverage period. If the carrier is unknown, provide the insurance agent's name and contact information.
5. Fill in Section C: Employee's Personal Information. Provide the injured employee’s full name, date of birth, mailing address, Social Security Number, contact number, and gender.
6. In Section D: Employee's Injury or Illness, detail the specifics of the incident, such as the time of injury, location, supervisor involvement, and a comprehensive description of how the injury occurred.
7. Move to Section E: Medical Treatment where you will indicate the date of the first treatment received by the employee and further medical treatment details.
8. Complete Section F: Return To Work by indicating if the employee stopped working and if they have returned, along with any reduced duties.
9. Fill out Section G: Employee's Work Information by providing the hire date, job title, and an overview of standard work activities.
10. In Section H: Employee's Payroll Information, include weekly gross pay, any additional compensation, typical work days, and payment details related to the injury day.
11. Lastly, in Section I: Additional Information, provide any relevant details not covered elsewhere. Ensure to sign the form and indicate who prepared it.
12. Save your changes and proceed to download, print, or share the completed form as needed.

Complete your Employer's Report of Work-Related Injury/Illness online today to ensure compliance and support your employees effectively.