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Y Hotline 1-800-243-3331 www.WorkforceSafety.com SFN 2828 (07/2014) PLEASE PRINT OR TYPE USING BLACK OR BLUE INK AND RETURN TO WSI. Please see reverse side for Fraud Warning and other information. SECTION 1 Completion of this section is required Claim Number Worker s Mailing Address City State nd Body Part Injured (Example: Left 2 /middle finger, right shoulder, left ankle.) AM PM Sex Marital Status F Single Married M Worker's Home/Cell Phone Number Zip What was the nature of the injur.
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Agenc FAQ
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All claims must be filed within one year after an injury or within two years after a death. The date of injury is the first date that a reasonable person knew or should have known that a work-related injury occurred.
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Estimated employer rates for workers' compensation in North Dakota are $1.14 per $100 in covered payroll. A number of factors can affect your premium, including: Payroll. Location.
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The employer is required to file an Employer's First Report of Injury or Illness [DWC FORM-001 Rev. 10/05] with the injured worker's insurance carrier, and the injured claimant or the claimant's representative within 8 days after the employee's absence from work or receipt of notice of occupational disease.
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First Report of Injury (FROI) The data transaction that occurs early in a workers' compensation claim. The FROI is most commonly the initial report of injury for a claim. A FROI may also be a denial of a claim. Subsequent Report of Injury (SROI)
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Nearly every employee in North Dakota must be covered by workers' compensation insurance, with some exceptions. Individuals who are exempt from mandatory coverage include: Sole proprietors. Partners in LLCs.
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1. $13.2 million workers comp settlement for ironworker struck by a car (California)
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Estimated employer rates for workers' compensation in North Dakota are $1.14 per $100 in covered payroll. A number of factors can affect your premium, including: Payroll.
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How Does Workers' Comp Work in North Dakota? If your employee gets hurt or sick from their job, North Dakota workers' compensation provides medical benefits to help cover their treatment costs. If they need to take time away from work to recover, it can also help replace most of their lost wages.
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