Employer Report of Injury Form

Instructions

Within TEN DAYS after receiving notice of the accident, an employer must complete an Employer’s Report of Injury and forward copies to the Commission and its insurance carrier or third-party administrator. It is strongly encouraged that this form be used to report the accident to the Commission online. It must be completed in its entirety.

IMPORTANT: The employer must notify the Commission of a work-related fatality by telephone, telegram or electronic filing no later than the next business day following a fatality.

Adobe ESign Form

Form

Claims_Employer Report and Injury 101_Master.pdf

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