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.
Note: For uninsured employers, this form should be used regardless of the date of injury.
This form is no longer accepted by the Commission for any injuries occurring on or after 10/1/2008 but can be used by the employer to send information about a workers’ compensation injury to their insurance carrier or claim administrator. If you decide to use this form for a pre-10/1/08 accident, please fill out all spaces provided with the information requested and forward the form directly to your point of contact at your insurance carrier/claim administrator. Claim administrators will use the information contained on the paper form to submit electronic data to the Commission.
For all pre-10/1/08 accidents, you are required to complete this paper First Report of Injury and submit it to the Commission in order to obtain a Jurisdiction Claim Number which is required for your EDI transactions.
The employer is responsible for accurately completing all sections of this form when an employee is injured. It should be typed or legibly printed, signed, and dated by the preparer. Send the original form to the claim administrator for the insurance company who provided insurance coverage on the date of the occurrence. The claim administrator will report this information to the Commission. Contact your workers’ compensation insurance provider for additional information.