workers compensation injury form

Get the free workers compensation injury form 2002-2021

WORKERS COMPENSATION FIRST REPORT OF INJURY OR ILLNESS EMPLOYER NAME ADDRESS INCL ZIP CARRIER/ADMINISTRATOR CLAIM NUMBER OSHA LOG CASE REPORT PURPOSE CODE JURISDICTION INSURED REPORT NUMBER EMPLOYER S LOCATION ADDRESS IF DIFFERENT INDUSTRY CODE LOCATION EMPLOYER FEIN PHONE CARRIER/CLAIMS ADMINISTRATOR CARRIER NAME ADDRESS PHONE POLICY PERIOD CLAIMS ADMINISTRATOR NAME ADDRESS PHONE NO TO CHECK IF APPROPRIATE SELF INSURANCE CARRIER FEIN POLICY/SELF-INSURED NUMBER ADMINISTRATOR FEIN...
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Welcome back to Dallas work comp calm in today's video I want to talk about reporting your injury to your employer in a prior video we discussed the concept of date of injury and how that helped to control a lot of the deadlines in your case one of those deadlines is the deadline to report your injury to your employer when we talk about reporting your injury to your employer we're talking about giving them proper notice they need to investigate your claim they need to figure out what happened they might need to talk to witnesses they might need to get you to a doctor but they need to know what happened so that they can take the steps necessary for them to report the claim to their insurance company proper notice is giving them an idea of what happened telling them what injuries that you have and that you believe that it's work-related the two things that they have to understand is that you believe that you have an injury and that that injury occurred at work once you give them that notice then you've satisfied the requirement under the law to tell them what happened the deadline is 30 days it's 30 days from the date of injury and you might remember date of injury in our prior video as the date that the injury occurred or the date in an occupational disease that you knew or should have known that you had a work-related injury so 30 days that you have an injury that it's work-related and who do you give that to who do you tell about your injury you have to give that information to a supervisor or to somebody in a management position it doesn't necessarily have to be your supervisor but it has to be somebody in management at the company that you work for once you've done that you satisfied your requirement to report your injury there may be multiple ways of doing it you could do it in writing maybe you have to fill out an accident report on the job if you do it in writing you want to keep a copy so that you will have proof that you did it if they follow up on your report and take you to the doctor then I think you can feel pretty comfortable knowing that they're not going to claim that you never told them anything there'll be a record at the doctor's office that they brought you in so when you have the injury notify somebody because the deadlines run it you