Instructions for the First Report of Injury form

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Section 1 - Employer

Click here for a sample form to use with these instructions.

1. Enter the complete name of your business and address as shown on your workers compensation policy. If your location is different than your mailing address, complete the section of your location address.
2. The policy number field must be completed with your workers compensation policy number as shown on your State Insurance Fund policy documents.
3. If you don't use organization codes, you can ignore this section. Policyholders with large facilities, or multiple locations, utilize the organization code to sort the quarterly report of claims. If you are interested in using an organization code, contact Risk Management at the State Insurance Fund.
4. Check the employer status box that accurately describes your business (sole proprietor, LLC, partnership, corporation, public, or other). Check the box to indicate if the injured worker was a corporate officer, partner, LLC member or sole proprietor. Indicate if the injured worker was a household member.

Section 2 - Employee

5. The employee's last name, first name, middle initial (make sure last name and first name are entered in the appropriate fields), address, and phone number should be completed showing the most current information available to you. Also enter the claimant's sex, Social Security number, date of birth, and marital status.
6. Enter the state where the employee was hired.
7. The occupation field should indicate the primary occupation of the claimant at the time of the accident or exposure.
8. Employment status indicates the employee's work status. Valid choices are full-time, part-time, seasonal, piece worker, or volunteer.
9. The date of hire should indicate the most recent hire date.
10. The class code should indicate the class code where the injured worker's wages were reported on your payroll. If you are unsure of the appropriate class code, make sure the occupation has been entered. This will help the Registration Unit determine the appropriate class code.
11. The injury date should indicate the date the accident happened. If the claim is for an ongoing problem or occupational disease (such as dermatitis or carpal tunnel), indicate the date that the employee informed you of the problem or date the employee first sought medical attention.

Section 3 - Wages

12. The wage rate - whether the rate is hourly, daily, weekly, monthly or other, the hours worked per week, and the number of days worked per week - must be entered on all claims involving time loss.

If the injured employee works a different number of hours and/or days each week, or the injured worker is seasonal, indicate "other" in the wage rate and leave the hours worked per week and number of days worked per week blank. Attach a copy of the injured worker's gross earnings for the 52 weeks preceding the date of injury. If the injured worker has various hours and days worked, the gross earnings must be broken down into weekly increments. For "seasonal" employee, the gross wages can be submitted in one amount. If board, lodging, other advantages, or gratuities are provided to the injured worker, the value must be entered in the appropriate field.

Section 4 - Accident or exposure

13. Indicate the address where the accident occurred. The county field is a reporting requirement of the Industrial Commission and must be entered. Also indicate if the injury occurred on the premises.
14. Indicate the time the injury occurred and the time the employee began work on the date of injury, if applicable.
15. To identify claims with time loss from work, enter:

• 15a)    Date last worked
• 15b)    Date disability began
• 15c)    Date returned to work
• 15d)    If fatal, enter the date of death

16. Indicate the date the employer was notified of the injury.
17. The injury type (strain, cut, etc.), part of body affected (right arm, left leg, etc.), and whether the body part was injured previously must be completed. Please be sure to indicate which side of the body was injured, right or left.
18. Indicate to whom the injury was reported and a phone number where that person can be contacted.
19. List equipment, materials or chemicals that were involved in the accident (scaffolding, paintbrush, paint, electric sander, etc.). This information also should be recorded for possible third party claims.
20. A detailed description of the accident should be entered in the How Injury/Illness Occurred field. Example: "The worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The worker's right wrist was broken in the fall." If the claim is for an ongoing problem or occupational disease, describe the type of work the employee does that could have caused the problem they are having.
21. Information regarding failure of a machine or product, whether safety equipment was provided and used, if accident was caused by any person or business other than the injured worker, co-worker or the employer, and if other workers were involved in the accident should be recorded for possible third party claims.

Section 5 - Medical

22. The original physician or hospital name (please do not abbreviate name) and address should be recorded in the appropriate field so the Fund can obtain the appropriate medical information. The box for the type of treatment received must be marked for reporting purposes.

Section 6 - Preparer

23. Mark the box indicating if anyone witnessed the accident. The person who prepared the report should indicate his or her name and title, a phone number where he or she can be reached, and the date the form was completed.
    

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