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Employer's First Report of Injury or Occupational Disease

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GEORGIA STATE BOARD OF WORKERS' COMPENSATION
NOTICE TO CONTROVERT

NOTICE TO CONTROVERT

Board Claim No.
 Employee Last Name
 Employee First Name
 M.I.
 SSN or Board Tracking #
 Date of Injury

A. IDENTIFYING INFORMATION

Phone Number
 Address

EMPLOYEE

Employee E-mail Address

Name
 Phone Number

Address

EMPLOYER

Employer E-mail Address

Name
 Insurer/Self-Insurer File #

INSURER/
SELF-INSURER

Name
 Phone Number

Address

CLAIMS
OFFICE



Claims Office E-mail Address
 SBWC ID# (five digit no.)

B. CONTROVERT TYPES

1. This serves as notice, pursuant to O.C.G.A. §34-9-221, that the right to compensation in this claim is being controverted on the following specific grounds:

2. This is notice, pursuant to O.C.G.A. §34-9-200 and Board Rule 205(b), that the compensability of the following medical treatment / test is being controverted for the following specific reasons:

3. If only part of the claim is being controverted, state the specific part of the claim and the reason(s) it is being controverted:

C. CERTIFICATE OF SERVICE

This is to certify that a copy of both sides of this notice has been sent to the employee / claimant(s), all counsel of record and any other person with a financial interest, as listed below:

Type or Print Name
 Signature
Phone Number
 E-mail Address
Date

This form must be filed with the State Board of Workers' Compensation. A copy of both sides of this form must be given to the employee and any other person with a financial interest in the claim including, but not limited to the employer, medical care provider(s) and attorney(s).

INFORMATION FOR THE INSURER/SELF-INSURER:

Board Rule 61(b)(1): An insurer who receives a Form WC-1 from an employer shall clearly stamp the date of receipt on the form, review Section A, and complete any unanswered questions. The insurer shall complete either Section B or Section C or Section D and, by the 21st day following the employer's knowledge of disability, forward the original to the Board and a copy to the employee.

Board Rule 61(b)(4): Form WC-3. Notice to Controvert Payment of Compensation. Complete Form WC-3 to controvert when a Form WC-1 has previously been filed. Furnish copies to employee and any other person with a financial interest in the claim. See subsections (d), (h), and (i) of Code §34-9-221 and Rule 221.

O.C.G.A. §34-9-221(d): If the employer controverts the right of compensation, it shall file with the Board, on or before the twenty-first day after knowledge of the alleged injury or death, a notice in accordance with the form prescribed by the Board, stating that the right of compensation is controverted and stating the name of the claimant, the name of the employer, the date of the alleged injury or death, and the ground upon which the right to compensation is controverted.

Board Rule 221(d): To controvert in whole or in part the right to income benefits or other compensation use Form WC-1 or WC-3. Failure to file the Forms WC-1 or WC-3 before the 21st day after knowledge of the injury or death may subject the employer/insurer to assessment of attorney's fees. See O.C.G.A. §34-9-108(b)(2)(3).

O.C.G.A. §34-9-221(h): When compensation is being paid without an award, the right to compensation shall not be controverted except upon the grounds of change in condition or newly discovered evidence unless a notice to controvert is filed with the Board within 60 days of the due date of first payment of compensation.

Board Rule 221(h)(1): A Form WC-3 shall not be used to suspend benefits if the only issue is length of disability. In these cases, suspend benefits by filing a Form WC-2 or follow the procedure outlined in Rule 240. If liability is denied subsequent to commencement of payment, but within 60 days of due date of first payment of compensation, file Form WC-3 in addition.

O.C.G.A. §34-9-221(i): When compensation is being paid with or without an award and an employer or insurer elects to controvert on the grounds of a change in condition or newly discovered evidence, the employer shall, not later than 10 days prior to the due date of the first omitted payment of income benefits, file with the Board and the employee or beneficiary a notice to controvert the claim in a manner prescribed by the Board.

Board Rule 221(h)(2): If income benefits have been continued for more than 60 days after the due date of first payment of compensation, benefits may be suspended only on the grounds of a change in condition or newly discovered evidence. File Forms WC-2 or WC-2(a). When controverting a claim based on newly discovered evidence, file Form WC-3 also.

O.C.G.A. §34-9-108(b)(2): If any provision of Code Section §34-9-221, without reasonable grounds, is not complied with and a claimant engages the services of an attorney to enforce rights under that Code Section and the claimant prevails, the reasonable fee of the attorney, as determined by the Board, and the costs of the proceedings may be assessed against the employer.

INFORMATION FOR THE EMPLOYEE:

This claim is being controverted for the reason(s) indicated on the front of this form. If you disagree, you should request a hearing by sending Form WC-14 to the State Board of Workers' Compensation at the address below. If you need a Form WC-14, please contact the State Board of Workers' Compensation at the phone numbers listed below or visit the website.

STATE BOARD OF WORKERS' COMPENSATION

270 Peachtree Street, N.W.

Atlanta, Georgia 30303-1299

In Atlanta: 404-656-3818

or: 1-800-533-0682

http://www.sbwc.georgia.gov

IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS' COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov

WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. §34-9-18 AND §34-9-19).

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What the Employer's First Report of Injury or Occupational Disease Is

The Employer's First Report of Injury or Occupational Disease is the standard workers' compensation form employers submit after an employee experiences a work-related injury or occupational illness. It documents the worker's identity, incident details, employer and payroll data, initial medical treatment, and time lost or anticipated. The report establishes the official claim record for insurers, state agencies, and internal HR case management; it triggers benefits review and helps preserve evidence for potential benefit determinations and return-to-work planning.

Why completing the First Report promptly matters

Timely, accurate reporting protects employee benefits, preserves employer defenses, and speeds claims handling with carriers and state agencies. A clear first report reduces disputes, supports medical case management, and helps control cost exposure through faster adjudication and return-to-work coordination.

Why completing the First Report promptly matters

Who typically prepares and receives this report

Employers, HR or safety managers, third-party administrators, and claims handlers usually prepare the report once notified of an injury.

  • Supervisors and HR representatives complete incident details, witness names, and immediate actions taken to secure the scene and start medical care.
  • Third-party administrators and insurers use the form to open claims, assign adjusters, and initiate benefit payments and medical authorizations.
  • Occupational health clinicians and onsite nurses supply treatment information and return-to-work notes used on the report for medical sections.

Recipients commonly include the employer file, the insurer or third-party administrator, and the appropriate state workers' compensation agency when required.

Key personnel involved

HR Manager

The HR Manager gathers incident facts, completes employer sections, and submits the report to the insurer and state portal. They coordinate with medical providers and maintain the internal case file, ensuring confidentiality and regulatory retention.

Claims Specialist

A Claims Specialist or third-party administrator reviews the first report to open the claim, notify the adjuster, request medical records if needed, and determine initial indemnity payments and workplace accommodations.

Essential security and compliance elements

Encryption: TLS 1.2/1.3; AES-256
Access Controls: Role-based permissions
Audit Trail: Timestamps and IP logs
HIPAA BAA: BAA for PHI handling
Retention: Secure, tamper-evident storage
Authentication: Multi-factor options

Potential penalties and claim risks

Late filing fines: State fines possible
I-9 or payroll exposure: Related compliance risk
OSHA referral: Investigation risk
Claim denial: Incomplete facts risk
Insurance premium increase: Higher future premiums
Legal exposure: Civil litigation risk

Common mistakes to avoid

  • Incomplete incident description or missing witness details, which delays insurer investigation and may weaken the employer's factual position.
  • Entering incorrect or inconsistent dates—injury date, report date, and first medical visit should match contemporaneous records to avoid disputes.
  • Using the wrong employer or payroll account numbers, leading to misrouted claims and payment delays with the carrier or state agency.
  • Delaying submission; late reports can trigger fines, increase investigation scope, and slow benefits for the injured worker.

Real-world examples of first report usage

Examples illustrate how employers complete the form and how it affects claim outcomes across industries.

Construction site laceration

A foreman documents a deep hand laceration and initial emergency care, including hospital transport

  • Medical transport recorded
  • The timely, detailed report accelerated carrier authorization for specialty follow-up care and reduced time away from work through expedited light-duty placement.

Healthcare facility exposure

An ER nurse reports a needle-stick with immediate post-exposure prophylaxis documented

  • Source testing initiated
  • Prompt reporting enabled occupational health to begin prophylaxis quickly and supported a clear claim decision while preserving the employee's confidentiality.

Step-by-step: completing the Employer's First Report

Follow these sequential steps to capture the facts, medical data, and employer information the carrier needs to open a claim.

  • 01
    Step 1: Collect employee and incident identifiers immediately.
  • 02
    Step 2: Record injury date, time, location, and witnesses.
  • 03
    Step 3: Document initial medical treatment and provider details.
  • 04
    Step 4: Submit to insurer and file internal copy for records.

Where the form goes and how it flows

After completion, route the report to the parties that need it and record proof of transmission.

  • Employer File: Keep a secured employer case record.
  • Insurer / TPA: Submit to open and assign the claim.
  • State Agency: File if your jurisdiction requires it.
  • Medical Provider: Share only necessary treatment details.

Key sections to complete on a professional first report

Ensure each major section is complete to avoid follow-up requests and support swift adjudication.

Employer Information

Legal name, address, employer identification numbers, policy or carrier name, and contact person for claim handling; accuracy ensures correct routing and premium allocation.

Employee Details

Full legal name, date of birth, address, job title, and hire date plus employee identification so records match payroll and HR systems for benefit calculations.

Incident Description

Concise factual narrative of how the injury occurred, tools or machinery involved, location, time, and witness names to preserve contemporaneous evidence.

Medical Treatment

Date, provider name and address, treatment rendered, and whether the employee was hospitalized; include return-to-work or work restrictions if provided.

Wage and Hours

Employee's average weekly wage, pay basis, and recent hours worked to assist the carrier with indemnity calculations and benefits estimates.

Employer Comments

Supervisor observations, corrective actions taken, and any safety measures implemented to prevent recurrence; factual statements support later defense or root-cause analysis.

Configuring an online first-report workflow

Set up the digital form so required fields, validation, and routing are enforced before submission.

Field Configuration
Employee ID Required; numeric validation
Injury Date MM/DD/YYYY; cannot be future date
Medical Provider Required when treatment indicated
Auto-Routing Send to insurer and HR automatically

Digital signing and submission considerations

Choose a platform that supports secure e-signatures, audit trails, and role-based access to protect PHI and claim data.

  • Formats supported: PDF, DOCX
  • Integrations: HR and claims systems
  • Authentication: Email, SMS, MFA

Confirm the vendor can meet HIPAA or state privacy requirements, supports encrypted storage, and can deliver signed copies with a robust certificate of completion for audit and insurer needs.

Timelines and reporting expectations

Review filing timelines for internal and external reporting; timeframes vary by state and by severity of the incident.

Immediate reporting:

Report fatalities or inpatient hospitalizations immediately, often within 24 hours.

Initial employer report:

Submit the first report as soon as practical, typically within 7 to 10 days in many jurisdictions.

Insurer notification:

Notify carrier promptly to avoid late-notice disputes or coverage complications.

OSHA reporting:

Separate OSHA rules may require 24-hour or 7-day reporting for certain events.

Internal deadlines:

Establish same-day supervisor reporting and 48–72 hour HR submission targets.

Comparing eSignature vendors for first-report workflows

Vendor pricing and compliance features influence total cost and suitability for workers' compensation workflows; signNow is listed first for comparison.

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 No No Yes, limited Yes, limited
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently asked questions about the Employer's First Report

Answers to common questions about when to file, corrections, e-signature validity, and document retention for first reports.


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