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Report a Workers' Compensation Claim Online
For a Workers' Compensation Claim only.
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Employer's First Report of Injury
Employer's FEIN
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Date of report
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Case or File#
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Is this a lost workday case?
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Employer's name
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Doing business as
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Employer's Phone (including Area Code)
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Employer's mailing address
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Employer's email address
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Nature of business or service
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SIC code
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Name of workers' compensation carrier/admin
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Policy/Contract #
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Self-insured?
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Employee's full name
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Employee's Birthdate
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Employee's Social Security Number
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Employee's mailing address
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Employee's Phone (Including Area Code)
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Employee's e-mail address
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Gender
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Female
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Marital Status
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Married
Single
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# Dependents
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Employee's average weekly wage
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Job title or occupation
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Date hired
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Time employee began work
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Date and time of accident
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Last day employee worked
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If the employee died as a result of the accident, give the date of death.
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Did the accident occur on the employer's premises?
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No
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Address of accident
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What was the employee doing when the accident occured?
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How did the accident occur?
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What was the injury or illness? List the part of body affected and explain how it was affected.
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What object or substance, if any, directly harmed the employee?
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Name and address of physician/health care professional
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If treatment was given away from the work site, list the name and address of the place it was given.
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Was the employee treated in an emergency room?
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Was the employee hospitalized overnight as an inpatient?
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Report prepared by
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Title and telephone #
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Email address
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