Get Firs St Repo Ort Of In Njury - Workforce Safety & Insurance

Filling out the FIRS ST REPORT OF INJURY form is an essential step in reporting workplace injuries or illnesses. This guide provides clear, comprehensive instructions for each section of the form to ensure accuracy and completeness while facilitating the submission process online.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the required information in Section 1, including the claim number, worker's mailing address, and the city and state. Clearly specify the body part injured, and provide the nature of the injury or illness along with details on how the incident occurred.
3. Continue in Section 1 by documenting the worker's phone number, sex, marital status, occupation, employer's name, and job site location. Enter the start time of the worker's shift and note the date the employer was notified and the name of the person who was informed.
4. In Section 2, provide details about the worker, including their full name, birth date, social security number, and rate classification. Indicate if the worker is a corporate officer or has had prior injuries to the affected body part. Additionally, confirm if the incident has caused the worker to miss five or more days of work.
5. Complete Section 3, which pertains to the medical provider’s completion. Enter the date of the first treatment and the diagnosis code. Address whether the incident has resulted in the worker missing five or more days of work and specify any restrictions or limitations that apply.
6. In Section 4, the employer should provide their completion details, including the employer's address and the time of the injury. Ensure the employer’s signature is included.
7. Review all entries for accuracy after completing the form. Make any necessary revisions before submitting.
8. Finally, save changes, download a copy for personal records, and share the form as required.

Complete your FIRS ST REPORT OF INJURY form online today to ensure timely processing of your workplace injury report.