First Report of Injury
This form is used to report a work place injury to the Commission or to the Insurance Carrier/Claim Administrator depending on the date of injury. For all injuries occurring on or after October 1, 2008, this form should only be used to notify the insurance carrier/claim administrator of a work place injury. For injuries that occurred before October 1, 2008, that have not been reported to the Commission, the employer should use this form to report the injury so that Jurisdiction Claim Number can be assigned.