First Report of Injury or Illness - Workers' Compensation
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Information about the employee
Best phone number for contact:
Mailing City, State, Zip
Email address for contact:
Information about the injury
Date of injury:
Time of injury (specify am or pm):
Date this injury was first reported
Describe, in detail, how the injury/illness occurred. Be specific about area of body affected (i.e. left index finger):
Will the employee be seeking medical treatment?
If you indicate no, you can still seek medical treatment up to 30 days from the injury.
Was the employee doing his/her regular job?
Worksite location of injury (be specific)
List of witnesses: