When must I file the report?

Deadlines vary by state and by carrier; check your state workers' compensation agency and insurer policy for the exact submission window before filing.

Can I sign the report electronically?

Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. §7001) and UETA where adopted; verify any state exceptions and consumer-disclosure requirements.

Does the report require notarization or witnesses?

Not typically for first reports; notarization and witness requirements are uncommon but may vary by state or specific carrier forms—confirm with the state board.

How do I correct an error after submission?

Contact the insurer or TPA to request an amendment and retain both original and corrected records; document the reason and who authorized the change.

What if medical information includes PHI?

Treat health information under HIPAA requirements; limit PHI in shared copies and ensure your eSignature provider supports HIPAA with a BAA when needed.

How long should I keep the report?

Retain per applicable rules: OSHA-related records five years (29 CFR §1904.33), HIPAA six years (45 CFR §164.530(j)), and state-specific longer periods where required.

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Employers First Report of Injury

Employers First Report of Injury

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT

Division of Workers' Compensation

Special Funds Section

REQUEST FOR OFFSET OF LIABILITY TO SUBSEQUENT INJURY FUND

Claimant

W.C. #

Social Security #

Employer

Carrier

Claim #

Insurance

Carrier

Date of Injury of

The hereby requests that the Director of the Division of Workers' Compensation be named as an interested party herein on behalf of the Subsequent Injury Fund. In support of this request, petitioner submits the following information:

If an offset is claimed pursuant to Section 8-46-101, C.R.S., complete section A, and if offset is claimed pursuant to Section 8-41-304, C.R.S., complete section B.

A. Prior Industrial Disability (Section 8-46-101, C.R.S.)

List prior workers' compensation cases below by employer, number, brief description of injury(ies) and award:

Employer

W. C. Number

Description of Injuries

Award

1.

2.

3.

B. Covered Occupational Disease (Section 8-41-304(2), C.R.S.)

Indicate the type(s) of exposure(s) alleged, the approximate dates of each, and the name and location of the employer in whose employ the exposure(s) allegedly occurred.

Type of Exposure

Approximate Date of Exposure

Employer

Address of Employer

1.

2.

(attach additional sheet(s) if necessary)

Date of Request

Signature of Requestor

NOTE:

A copy of this request and all pleadings, notices, reports and documents thereafter filed must be served upon the Director of the Division of Workers' Compensation. Submit these with this form to the Division of Workers' Compensation, Special Funds Section, P.O. Box 300009, Denver, CO 80203-0009. Where an assistant attorney general has entered an appearance for the Director in a case, such service shall be made upon that attorney.

C.R.S. Section 10-1-128(6)(a) states: "It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies."

WC63 Rev. 01/06

What the Employers First Report of Injury Is

The Employers First Report of Injury is the employer-originated document used to notify a workers' compensation carrier and, where required, the state agency of a workplace injury or occupational illness. It captures key facts — employee identity, date and time, injury location, immediate treatment, and work status — to open a claim and begin benefit administration. Accurate, timely reporting helps preserve claim rights, supports OSHA and workers' compensation recordkeeping, and enables medical care coordination and insurer investigation.

Stepwise process to complete and file the report

A clear sequence reduces omissions and speeds claim intake for the Employers First Report of Injury.

01

Gather Details: Collect employee, incident, witness, and payroll information before beginning the form.
02

Complete Form: Enter required fields, check for consistency with payroll and medical records.
03

Review: Confirm dates, names, and treatment details; resolve discrepancies before submission.
04

Submit: Send to the insurer and file any state-mandated report within the applicable timeframe.

Who typically completes the Employers First Report of Injury

Employers and designated staff complete the first report to start claims handling and regulatory compliance.

Human resources and payroll — assemble employee identifiers, hire date, wage data, and job classification for claims.
On-site supervisors and safety officers — document incident circumstances, controls in place, and witness contact information.
Claims administrators and TPA staff — validate data, send to insurer, track medical bills, and coordinate benefits.

Core sections to include in a professional first report

A complete Employers First Report of Injury contains sections that identify parties, describe the incident, capture medical response, and indicate immediate work status for claims intake.

Employee Information

Full legal name, date of birth, employee ID or SSN (as permitted), job title, hire date, and contact information to identify the claimant accurately.

Employer Details

Legal business name, FEIN/EIN, mailing address, primary contact, and payroll unit to ensure correct carrier assignment and premium accounting.

Incident Specifics

Exact date, time, work location, task being performed, and sequence of events that led to the injury for adjudication and root-cause analysis.

Injury Description

Body part(s) affected, specific nature of injury (e.g., laceration, fracture), and observed signs to support medical assessment and coding.

Medical Response

Initial treatment provided, name and address of treating provider or facility, and whether ambulance transport occurred.

Work Status

Indicate returned to work, work restrictions, or off work, and expected return date if known to guide wage replacement benefits.

Essential data elements to provide (short checklist)

Employee Name: Full legal name

Employer Identifier: FEIN or EIN

Incident Date: MM/DD/YYYY

Location: Street, city, state

Injury Summary: Brief mechanism description

Medical Provider: Facility name or clinic

Consequences of incomplete or late reporting

Claim Delay: Benefits and care delayed

Denial Risk: Incomplete facts may trigger denials

Regulatory Fines: State penalties possible

OSHA Exposure: Recordkeeping risk (29 CFR §1904.33)

Insurance Costs: Higher premiums over time

Legal Liability: Increased litigation exposure

Typical filing and notification workflow

A concise routing flow clarifies recipients and timing for the Employers First Report of Injury.

Prepare Report: Populate fields with verified employee and incident data.
Notify Insurer: Send completed report to the workers' comp carrier or TPA.
Inform Safety: Provide the safety team and supervisor with a copy for follow-up.
Retain Record: Store signed report per retention policy and regulatory rules.

Digital filing and format considerations

Use PDF or DOCX formats for signed reports and preserve an audit trail and copy for the claim file.

File Formats: PDF, DOCX accepted by most carriers
Integrations: Salesforce, NetSuite, Google Workspace supported
Security: TLS in transit; AES-256 at rest

Timing and deadlines to check before submission

Confirm both carrier-specific and state-mandated deadlines; severe incidents may require expedited notification to authorities and carriers.

Severe Incident Reporting:

Follow OSHA and state reporting rules; see 29 CFR §1904.39 and state guidance.

Carrier Notification:

Submit within the insurer's required window or risk delayed benefits.

Internal Deadlines:

Many employers require same-day reporting to HR and safety teams.

Medical Follow-up:

Document treating provider information within 24–72 hours where possible.

Record Retention Start:

Retention begins on report creation and claim opening date.

eSignature vendor comparison for filing and signing reports

Basic vendor pricing and feature availability to help plan for eSignature-enabled report submission; vendor details and plan terms vary.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	Yes, 7-day trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Varies	Varies	Varies	Varies
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently asked questions about the Employers First Report of Injury

Common questions and concise answers to help resolve preparation, signing, and filing issues for the Employers First Report of Injury.

Need help? Contact support

When must I file the report?
Deadlines vary by state and by carrier; check your state workers' compensation agency and insurer policy for the exact submission window before filing.
Can I sign the report electronically?
Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. §7001) and UETA where adopted; verify any state exceptions and consumer-disclosure requirements.
Does the report require notarization or witnesses?
Not typically for first reports; notarization and witness requirements are uncommon but may vary by state or specific carrier forms—confirm with the state board.
How do I correct an error after submission?
Contact the insurer or TPA to request an amendment and retain both original and corrected records; document the reason and who authorized the change.
What if medical information includes PHI?
Treat health information under HIPAA requirements; limit PHI in shared copies and ensure your eSignature provider supports HIPAA with a BAA when needed.
How long should I keep the report?
Retain per applicable rules: OSHA-related records five years (29 CFR §1904.33), HIPAA six years (45 CFR §164.530(j)), and state-specific longer periods where required.

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