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.

E-sign Electronic Submission Form

Printable Form

Claims_Employer Report and Injury 101_Master.pdf

Related Forms

Form Name
Request for Hearing Form
Request for Hearing Withdrawal Form
Employer Report of Injury Form
Request for Continuance Form
Worker’s and Physician’s Report of Injury Form
Worker’s Report of Injury Form
Request to Change Doctors Form
Request to Leave State Form
Annual Report of Income Form
Notice of Intent to Suspend Form
Petition to Reopen Form
Petition for Rearrangement Form
Dependent Benefits Claim Form
Professional Employer Agreement Form
Bodily Fluids Work Exposure Form
Employee Rejection of Terms Form
Employee Revocation of Rejection of Terms Form