When must I submit the First Report?

Submit as soon as possible after an incident; many insurers expect notice within 24–72 hours and some states require filing within specific days. Verify insurer policy and state reporting rules to avoid fines or delayed benefits.

Who should sign the report on behalf of the employer?

A supervisor, HR representative, or authorized company officer should sign. The signer must be able to attest to the facts provided and to receive follow-up communications from the insurer or state agency.

Can the First Report be completed and signed electronically?

Yes—electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retention requirements are met. Confirm any industry or state exceptions first.

What privacy rules apply to medical information on the form?

When the report contains protected health information, HIPAA applies to covered entities and business associates; implement safeguards and execute a BAA when required to protect PHI and meet 45 CFR §164.530(j) retention rules.

How do I correct an error after submission?

Provide an amended report to the insurer and retain both versions with an explanation. Follow insurer and state procedures for corrections and document who authorized the change.

How long must I keep these reports?

Retain per the longest applicable rule: IRS 3 years (IRC §6501(a)), OSHA injury records 5 years (29 CFR §1904.33), HIPAA 6 years (45 CFR §164.530(j)), and state-specific extensions where applicable.

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Employer's First Report of Injury or Illness

Employer's First Report of Injury or Illness

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

Workers Compensation – First Report of Injury or Illness

Employer (Name & Address incl ZIP)

Carrier/Administrator Claim Number

OSHA Log Case #

Report Purpose Code

Jurisdiction

Jurisdiction Claim Number

Insured Report Number

Employer's Location Address (if different)

Location #

Phone #

Carrier/Claims Administrator

Carrier (Name, Address, & Phone #)

Policy Period

Claims Administrator (Name, Address & Phone No)

Self Insurance

Carrier FEIN

Policy/Self-Insured Number

Administrator FEIN

Employee/Wage

Name (Last, First, Middle)

Date of Birth

Social Security Number

Date Hired

Sex

Male Female Unknown

Marital Status

Unmarried / Single / Divorced Married Separated Unknown

Address (incl ZIP)

Phone #

# of Dependents

NCCI Class Code

Occupation/Job Title

Employment Status

Rate

Per

Days Worked/Week

Full Pay for Day of Injury?

Yes No

Did Salary Continue?

Yes No

Occurrence/Treatment

Time Employee Began Work

Date of Injury/Illness

Time of Occurrence

Last Work Date

Date Employer Notified

Date Disability Began

Contact Name/Phone Number

Type of Injury/Illness

Part of Body Affected

Did Injury/Illness/Exposure Occur on Employer’s Premises?

Yes No

Department or Location Where Accident or Illness Exposure Occurred

All Equipment, Materials, or Chemicals Employee Was Using When Accident or Illness Exposure Occurred

Specific Activity the Employee Was Engaged In When the Accident or Illness Exposure Occurred

Work Process the Employee Was Engaged In When Accident or Illness Exposure Occurred

How Injury or Illness/Abnormal Health Condition Occurred

Cause of Injury Code

Date Returned to Work

If Fatal, Give Date of Death

Were Safeguards or Safety Equipment Provided?

Yes No

Were They Used?

Yes No

Physician/Health Care Provider (Name & Address)

Hospital or Off Site Treatment (Name & Address)

Initial Treatment

No Medical Treatment
Minor: By Employer
Minor Clinic/Hosp
Emergency Care
Hospitalized > 24 Hours
Future Major Medical/Lost Time Anticipated

Witnesses (Name & Phone #)

Date Administrator Notified

Date Prepared

Preparer's Name & Title

Phone Number

General inquiries on Form 1 can be answered by the AWCC Support Services Division. Questions on a specific Form 1 may be directed to the Research and Statistics Section, which processes the accident reports.

Ark. Code Ann. §11-9-529 allows employers 10 days to report injuries. Those involving either more than 7 days of lost time or indemnity payments require Form 1. Also, a Form 1 is required for all controversions including a medical-only case.

Employers do NOT fill in the shaded areas.

What the Employer's First Report of Injury or Illness is and when it is used

The Employer's First Report of Injury or Illness is a standardized workplace incident record completed by an employer after an employee sustains a work-related injury or occupational illness. It documents facts needed for workers' compensation claims, internal case management, and insurer or state agency reporting. The form typically records the employee's identity, employer details, event description, date and time, injury location, treatment sought, lost work time, and witness information. Completing the report promptly preserves evidence, begins claims processing, and helps employers meet regulatory reporting and benefit-administration obligations.

Why accurate First Reports matter for claims and compliance

A complete, timely Employer's First Report accelerates workers' compensation adjudication, reduces administrative delays, and supports OSHA and insurer recordkeeping. It establishes a clear factual baseline for the claim, protects employer and employee interests, and helps manage return-to-work planning.

Who typically completes and uses this report

Employers, HR or safety staff, supervisors, and third-party administrators normally complete the form after an incident.

Supervisors or managers who witnessed the incident or received initial notification and can describe event details.
HR, risk, or safety professionals responsible for official recordkeeping, claims initiation, and follow-up actions.
Third-party administrators or insurers who receive the report to begin benefits adjudication and medical management.

Essential parts of a professional Employer's First Report of Injury or Illness

A well-prepared First Report captures identity, event chronology, medical treatment, and administrative details so claims handlers and regulators can act without delay. Each section should be factual, legible, and supported by dates, locations, and responsible contacts.

Employee Details

Full legal name, date of birth, employee ID, home address, job title, employment status, and department to ensure correct claim assignment and contact.

Employer Details

Employer legal name, federal EIN or state account number, business address, contact person, and phone for insurer and agency correspondence.

Incident Description

Concise factual narrative of what happened, sequence of events, equipment involved, and environmental conditions; avoid speculation or assigning fault.

Date and Time

Exact date and time of injury or illness onset, plus shift information and any relevant prior exposure dates for occupational diseases.

Medical Treatment

Whether first aid or professional care was provided, name and address of treating facility or clinician, and transport to medical care if applicable.

Work Status and Lost Time

Indicate whether employee returned to work, restricted duty, or was off work and include anticipated return date if known for benefit calculations.

Required data elements to include on the form

Employee name: Full legal name

Date of injury: MM/DD/YYYY

Time of injury: 24- or 12-hour time

Location: Street and facility

Treatment: Provider or first aid

Witnesses: Names and contacts

Step-by-step: completing the Employer's First Report of Injury or Illness

Follow these sequential steps to ensure accuracy and consistent submission to insurers and regulators.

01

Gather facts: Collect witness statements, time, place, and immediate medical actions.
02

Enter employee data: Use legal name and correct identifiers to match payroll and benefits records.
03

Describe the event: Write a neutral, chronological narrative focused on actions and outcomes.
04

Submit timely: Send to insurer and retain an employer copy per retention rules.

How to set up an online First Report workflow

Configure fields, routing, and authentication so online submissions meet insurer and regulatory expectations.

Field	Configuration
Required fields	Employee name \| Date \| Location
Routing	Send to HR \| Insurance adjuster
Authentication	Email link \| SMS code optional
Retention	Auto-archive \| Audit log retained

Where to send the completed First Report

Use the correct routing channels for prompt claims handling and regulatory compliance.

Insurer or TPA: Primary recipient for claims intake and benefit administration.
Internal HR / Risk: Employer copy for case management, accommodation, and return-to-work planning.
State agency: Submit when state law or fund rules require a report to the workers' compensation board.
OSHA if required: Report to OSHA only when the incident meets OSHA recordability or reporting thresholds.

Digital signing and file formats to support eSubmission

Choose a platform that produces auditable signed PDFs and supports required integrations and authentication.

File formats: PDF, DOCX supported
Integrations: HRIS, ATS, claims systems
Authentication: Email link or two-factor

Typical timing and deadlines to observe after an incident

Deadlines vary by state and insurer; prioritize prompt completion and submission to avoid penalties or delayed benefits.

Prompt internal reporting:

Notify HR and supervisor immediately; collect facts same day.

Insurer submission window:

Many insurers expect initial notice within 24–72 hours; check carrier policy.

State filing:

Some states require employer or insurer filing within days to weeks; verify local statute.

OSHA reporting:

Report fatalities and severe injuries per OSHA timelines when applicable.

Recordkeeping retention:

Keep employer copies per retention rules and regulatory guidance.

Common mistakes to avoid when preparing the First Report

Incomplete or approximate dates and times that impede event reconstruction and delay claims adjudication.
Using informal or speculative language instead of neutral, fact-based incident descriptions and observable details.
Failing to include accurate witness contacts, which can make corroboration difficult during the investigation.
Omitting employee identifiers or mismatching payroll records, causing routing errors and TIN or benefits issues.

Penalties and risks from incorrect or late reporting

Late filing: Possible fines and delayed benefits

Incorrect data: Claim denials or administrative burden

Missing signatures: Questioned validity of submission

Privacy violations: HIPAA issues if health data mishandled

OSHA exposure: Citations if OSHA reporting rules ignored

Audit risk: Increased scrutiny during claims review

Real-world examples of electronic reporting and document workflows

Organizations across industries use electronic forms and eSignatures to streamline incident reporting and claims initiation.

Optica Ventures LLC

Optica adopted online signing for operational forms and internal reports to reduce turnaround.

Staff found the interface simple and accessible across devices.
As COO Brian Fitzgibbons noted, the intuitive platform helped the team and customers complete necessary paperwork quickly and consistently for business processes.

Fertility Centers of Illinois

The organization moved patient and HR consent forms online to centralize records.

IT and operations integrated document flows with core systems.
John Butler, Founder, stated the platform met compliance and integration needs while enabling secure signature capture across desktop and mobile workflows.

Practical tips for accurate and efficient completion

Adopt consistent processes, templates, and validation checks to minimize errors and speed insurer acceptance.

Standardize templates

Use a single approved First Report template for all sites and ensure required fields are marked mandatory to prevent incomplete submissions.

Train supervisors

Provide brief, scenario-based training on what constitutes a reportable injury and how to collect witness and treatment information on scene.

Keep copies

Retain a secure employer copy of every report and store supporting evidence—photos, timecards, safety checks—for the retention period.

Use e-sign and audit trails

Capture signer attribution and timestamps for every submission to support claims defense and regulator inquiries.

eSignature vendor comparison relevant to First Report workflows

Basic vendor pricing and feature differences that affect high-volume incident reporting workflows and HIPAA-sensitive use cases.

	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	7-day free trial	Varies	Varies	Varies	Varies
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 of Injury or Illness

Answers to common questions to help employers complete, submit, and retain First Reports correctly.

Need help? Contact support

When must I submit the First Report?
Submit as soon as possible after an incident; many insurers expect notice within 24–72 hours and some states require filing within specific days. Verify insurer policy and state reporting rules to avoid fines or delayed benefits.
Who should sign the report on behalf of the employer?
A supervisor, HR representative, or authorized company officer should sign. The signer must be able to attest to the facts provided and to receive follow-up communications from the insurer or state agency.
Can the First Report be completed and signed electronically?
Yes—electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retention requirements are met. Confirm any industry or state exceptions first.
What privacy rules apply to medical information on the form?
When the report contains protected health information, HIPAA applies to covered entities and business associates; implement safeguards and execute a BAA when required to protect PHI and meet 45 CFR §164.530(j) retention rules.
How do I correct an error after submission?
Provide an amended report to the insurer and retain both versions with an explanation. Follow insurer and state procedures for corrections and document who authorized the change.
How long must I keep these reports?
Retain per the longest applicable rule: IRS 3 years (IRC §6501(a)), OSHA injury records 5 years (29 CFR §1904.33), HIPAA 6 years (45 CFR §164.530(j)), and state-specific extensions where applicable.

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