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DATE OF B IRTH SOCIAL SECURITY NUMBER C ITY PHONE NUMBER EDUCATION LESS T HAN HIGH SCHOOL GED OR HIGH SCHOOL DIPLOMA B EYOND HIGH SCHOLL GENDER M ALE FEMALE STATE POSTAL C ODE M ARITAL STATUS M ARRIED SEPARATED NOT UNKNOWN UNKNOWN NUMBER OF DEPENDENTS Wages DATE HIRED GROSS EARNINGS FOR FOUR PAY DATE /AMOUNT DATE /AMOUNT DATE /AMOUNT DATE /AMOUNT PERIODS PRECEDING THE INJURY EMPLOYMENT STATUS FULL T IME PART T IME SEASONAL VOLUNTEER IN ADDITION TO GROSS EARNINGS CITED ABOVE W.

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How to fill out the First Report - Creative Risk Solutions online

Completing the First Report - Creative Risk Solutions is an important step in filing a workers' compensation claim. This guide provides clear instructions to help you accurately fill out the form online, ensuring that you include all necessary information for your claim.

Follow the steps to correctly complete the First Report.

  1. Press the ‘Get Form’ button to access the First Report and open the document in your chosen online editor.
  2. Begin by filling out the worker's information. Include the last name, first name, middle initial, home address, date of birth, social security number, city, state, postal code, and phone number.
  3. Complete the education section by selecting the highest level of education attained: less than high school, GED or high school diploma, or beyond high school.
  4. Fill in the gender field by selecting male or female and complete the marital status and number of dependents sections.
  5. Provide wage information including date hired and gross earnings for the four pay periods preceding the injury. Make sure to specify the employment status as full time, part time, seasonal, or volunteer.
  6. Describe the accident in detail. Include the description of the accident, cause of injury, date disability began, and any relevant information about witnesses and equipment provided.
  7. Complete the medical information section by providing the name and address of the attending physician and hospital, as well as the type of initial medical treatment received.
  8. Review the form for accuracy and ensure that all mandatory fields are completed. Sign and date the form to certify the information is correct.
  9. Once completed, save any changes, and download a copy for your records. You may also choose to print or share the form as necessary.

Take the next step for your workers' compensation claim by completing the First Report online today.

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A DWC 1 is the form that is filled out to report an injury to your employer, and officially initiate a workers' compensation claim. DWC stands for Division of Workers' Compensation, this is the government agency that monitors workers' compensation claims and law.

You should immediately report your injury to your employer or immediate supervisor. Your employer must fill out a form, sometimes called a First Report of Injury, for every injury that occurs in the workplace. Make sure that your employer fills out a form for you.

Within 5 days of your initial examination, for every occupational injury or illness, send two copies of this report to the employer's workers' compensation insurance carrier or the insured employer. Failure to file a timely doctor's report may result in assessment of a civil penalty.

The 14- and 30-Day Rules New Jersey's workers' comp law sets an initial expectation that employees report workplace injuries within fourteen days. [1] However, the law doesn't draw a hard line here.

What is a first report of injury form New Jersey? Form 1A-1 First Report of Injury (FROI). As soon as you have been notified of a work-related injury, please fill out this form and submit it to EMPLOYERS. This form must be completed within three days from notice of a work-related injury.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Help Portal
Legal Resources
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232