Employer's First Report of Occupational Injury or Disease Form

After you have been injured on the job, you will need to fill out several forms, preferably with the help of an attorney. During the initial meeting with your workers’ compensation lawyer, you will need to complete the Employer’s First Report of Occupational Injury or Disease document. This form will include the following information:

• Employee’s social security number
• Employee’s name and address
• Occupation
• Extent of the injury
• Employee’s wages
• Employer information

Make sure your attorney reviews this form to ensure all the information is correct. Once it has been reviewed, the document should be submitted to your state’s Department of Labor Office and their insurance carrier.

Notice of Accidental or Occupational Disease Form

After filing the Employer’s First Report of Occupational Injury or Disease form, the injured worker must complete the Notice of Accidental or Occupational Disease document to obtain workers’ compensation benefits from the employer. Once completed, the employer must sign the form before it is sent to the state Department of Labor Workers’ Compensation Division.  If the employer refuses to sign the form, the injured employee should send the document to the Compensation Division with a letter stating the employer’s refusal to sign the form and acknowledge the work-related injury. The purpose of this form is to explain the events of the accident and to detail the costs of relevant medical treatment.

Workers' Compensation Medical Form

The Workers’ Compensation Medical Form must be completed during each doctor visit. This document must be submitted to the workers’ compensation insurance carrier within 10 days of any medical appointment. If the injured employee fails to file this form, he or she may be fined $2,500.

Most of this form is filled out by the doctor after the examination of the injured employee. The document will detail how the treatment is progressing as well as any physical improvements in the worker.

Report of Extended Disability

If the doctor expects the worker’s injury or illness will last six months or longer, the insurer of benefits must complete a Report of Extended Disability Form with the state’s Department of Labor. This form will include personal information of the injured employee, the date of the accident and the disability date. A workers’ compensation attorney can help you complete this form, as well as the other documents described above.