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Report of Injury by Employee to Employer to be Filed with Worker's...

Guam Report of Injury by Employee to Employer to be Filed with Worker's Compensation Agency of State

Category:

Workers Compensation - Injury Reports

State:

Multi-State

Control #:

US-01494BG

Format:

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Description

Workers' compensation laws are designed to ensure payment by employers for
some part of the cost of injuries, or in some cases of occupational diseases, received by employees in the course of their work. Worker's compensation legislation requires the employer to furnish a reasonably safe place to work, suitable equipment, rules and instructions. State workers' compensation statutes vary by state. The Federal Employment Compensation Act covers non-military federal employees or those workers employed in some significant aspect of interstate commerce.

The compensation acts require that notice of the fact of injury be given to the employer, or to the compensation board or commission, or to the insurance carrier, or to all of them. This form is a generic example that may be referred to when preparing such a form for your particular state. It is for illustrative purposes only. Local laws should be consulted to determine any specific requirements for such a form in a particular jurisdiction.

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How to fill out Report Of Injury By Employee To Employer To Be Filed With Worker's Compensation Agency Of State?

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FAQ

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.

Form CA-1 is used for a traumatic injury (a medical condition resulting from an incident or activity occurring during one work shift). Form CA-2 is for an occupational disease (a medical condition resulting from an incident or activity occurring over more than one work shift).

The LS-202 must be filed through SEAPortal ( ) or by mail at: OWCP/DFELHWC, 400 West Bay Street, Room 63A, Box 28, Jacksonville, FL 32202. See Document Submission and Communication with OWCP FAQ #15.

The CA-1 form is used if the employee has sustained a Traumatic Injury on the job. Traumatic Injury - A wound or other condition of the body caused by external force, including stress or strain.

(To be eligible for continuation of pay, the employee, or someone acting on his/her behalf, must file Form CA-1 within 30 days following the injury and provide medical evidence in support of disability within 10 days of submission of the CA-1.

The CA-1 form, with original signatures, will be filed in the district injury compensation (HRM) office. If your injury did not result in lost time from work or any medical expense, or first aid treatment only, your claim will not be submitted to OWCP for creation of a case.

Regardless of the category of the medical condition, your first concern will be to determine if your employee needs immediate medical care. If immediate care is required, assist in making arrangements for your employee to go to the nearest health care facility or to their private health care provider.

To be eligible for COP, you must submit a CA-1 within 30 days of the injury. If disabled and claiming COP, you must submit medical evidence supporting your disability to your employing agency within 10 workdays.

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