Employer's first report of injury form in Word and Pdf formats
First Report Of Injury Form. Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. Part of body injured or exposed* 6.
Employer's first report of injury form in Word and Pdf formats
Your insurer will report the injury to the department of labor and industry (department), when necessary. Web first report of injury. Date and time of accident (mm/dd/yyyy) (hh:mm am/pm) 4. The employer must also send a. Part of body injured or exposed* 6. Web this form quickly to allow your insurer time to investigate the claim. Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. Web the use of this form is required under the provisions of the tennessee workers'compensation law and must be completed and filed with your insurance carrier immediately after notice of injury. Web the employer is responsible for accurately completing all sections of this form when an employee is injured. Filing online using the first report of injury management system (for insurance companies only)
Date and time of accident (mm/dd/yyyy) (hh:mm am/pm) 4. Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. Part of body injured or exposed* 6. Date and time of accident (mm/dd/yyyy) (hh:mm am/pm) 4. This can be done via telephone, facsimile or electronic transmission, to be followed by the froi form within seven days of the occurrence. You may file your first report of injury (form 101), your monthly payment reports (form 107) and a request for extension of time online using the first report of injury management system. Department of labor (see instructions on reverse) office of workers' compensation programs omb no. Web the employer is responsible for accurately completing all sections of this form when an employee is injured. Web this form quickly to allow your insurer time to investigate the claim. Send the original form to the claim administrator for the insurance company who provided insurance coverage on the date of the occurrence. Filing online using the first report of injury management system (for insurance companies only)
