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Workers Compensation First Report of Injury or Illness

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WORKERS COMPENSATION - FIRST REPORT OF INJURY OR ILLNESS

General

Employer (Name & Address incl. zip)

Carrier Administrator Claim Number

Report Purpose Code

Jurisdiction

Jurisdiction Claim Number

Insured Report Number

Employer's Location Address (if different)

Location No.

SIC Code

Employer FEIN

Phone No.

Carrier (Name, Address & Phone Number)

Policy Period

TO

Claims Admin (Name, Address & Phone Number)

Carrier FEIN

Policy Number or Self-Insured Number

Administrator FEIN

Agent Name & Code Number

Employee / Wage

Legal Name (Last, First, Middle)

Date of Birth

Social Security Number

Date Hired

State of Hire

Address (Incl. Zip)

Sex

Marital Status

Occupation/Job Title

Phone

No. of Dependents

Employment Status

NCCI Class Code

Wage Rate

Day

Month

# Days Worked/WK

Full Pay for Date of Injury?

$ Week

Other

# Hrs Worked per Day

Did Salary Continue?

Occurrence

Time Employee Began Work

Date of Injury or Illness

Time Occurred

Last Work Date

Date Employer Notified

Date Disability Began

Employer Contact Name/Phone Number

Type of Illness/Injury

Part of Body Affected

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

Type of Illness/Injury Code Part of Body Affected Code

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. Describe the sequence of events and include any objects or substances that directly injured the employee or made the employee ill.

Cause of Injury Code

Date Returned to Work

If Fatal, Date of Death

Were Safeguards or Safety Equipment Provided?

Were they used?

Treatment

Physician/Health Care Provider (Name & Address)

Hospital (Name & Address)

Initial Treatment

Witness to Accident (Name & Phone Number)

Date Administrator Notified

Date Prepared

Preparer's Name & Title

Preparer's Phone Number

State Information / Signature

Applicable in Alaska

A person who willfully makes a false or misleading statement or representation for the purpose of obtaining or denying a benefit or payment is guilty of theft by deception.

Applicable in Arkansas

Any person or entity who willfully and knowingly makes any material false statement or representation for the purpose of obtaining any benefit or payment, or for the purpose of defeating or wrongfully decreasing any claim for benefit or payment or obtaining or avoiding worker's compensation coverage or avoiding payment of the proper insurance premium (or who aids and abets for either said purpose), under this chapter shall be guilty of a Class D. felony.

Applicable in California

Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony.

Applicable in Connecticut

This form must be completed in its entirety. Any person who intentionally misrepresents or intentionally fails to disclose any material fact related to a claimed injury may be guilty of a felony.

Applicable in Delaware and Oklahoma

Any person who, knowingly and with intent to injure, defraud, or deceive any Insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. The lack of such a statement shall not constitute a defense against prosecution under this section. *Delaware Statutes Regulation: Del #C Section 913(B)

Applicable in Florida

Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company or self-insured program, files any statement of claim containing any false or misleading information is guilty of a felony of the third degree.

Applicable in Idaho

Any person who Knowingly and with the intent to injure, Defraud, or Deceive any Insurance Company, Files a Statement of Claim Containing any False, Incomplete or Misleading information is Guilty of a Felony.

Applicable in Indiana

A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.

Applicable in Kentucky and New York

Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. In New York, such person shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Applicable in Michigan

Any person who knowingly and with intent to injure or defraud any insurer submits a claim containing any false, incomplete, or misleading information shall, upon conviction, be subject to imprisonment for up to one year for a misdemeanor conviction or up to ten years for a felony conviction and payment of a fine of up to $5,000.00.

Applicable in Minnesota

A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

Applicable in Nevada

Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete or misleading information concerning a material fact is guilty of a felony.

Applicable in New Hampshire

Any person who, with purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

Applicable in New Jersey

Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

Applicable in Ohio

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Applicable in Pennsylvania

Any person who knowingly and with intent to injure or defraud any insurer files a claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years or payment of a fine of up to $50,000.

Applicable in Utah

Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison.

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What the Workers Compensation First Report of Injury or Illness Is

The Workers Compensation First Report of Injury or Illness is the initial written record created after a work-related injury or occupational illness to document the event, the injured worker, and the injury details. Employers or their designated representatives normally complete this report to notify the insurer, claims administrator, or state workers' compensation agency. The form collects facts needed to open a claim, begin medical case management, and determine compensability, lost time, or wage replacement obligations. Accurate completion supports timely benefits and reduces disputes during claim intake and adjudication.

Why a Timely and Accurate First Report Matters

Completing an accurate first report establishes the official claim record, triggers insurer workflows, and protects both employer and worker rights under state workers' compensation laws.

Why a Timely and Accurate First Report Matters

Who Typically Prepares and Receives the First Report

Employers, supervisors, HR staff, safety officers, and third‑party administrators commonly prepare or submit the first report to insurers and regulators.

  • Employer representatives who witnessed or were notified of the incident and can provide factual details about time, location, and job task.
  • Human resources or risk management staff who coordinate medical care, return-to-work planning, and claims intake with the insurer.
  • Third-party administrators and insurance adjusters who receive the form to open a claim, assign a claim number, and begin investigation.

Accurate routing and clear ownership during intake reduce delays, support benefits delivery, and help meet state-specific reporting expectations.

Key Signatory Roles

HR Manager

The HR Manager often completes or oversees the form, ensuring the employer portion is accurate, that necessary attachments are included, and that the report is submitted to the insurer within the employer's required timeframe.

Claims Coordinator

A Claims Coordinator or third-party administrator reviews incoming reports, assigns claim handlers, and communicates with medical providers and the employer to manage benefits and return-to-work steps.

Essential Parts of a Professional First Report

A complete first report contains sections for identity, incident details, medical treatment, employment data, witness information, and employer certification to enable claim intake and early case decisions.

Worker Identification

Full legal name, date of birth, home address, contact phone, employee ID, and job title to uniquely identify the injured worker for benefits and payroll matching.

Incident Details

Exact date and time, location, task being performed, description of how the injury occurred, and body parts affected to establish causation and exposure context.

Medical Treatment

Name and address of treating facility or provider, date of first treatment, whether emergency care was required, and authorization for continued care and records release.

Employment Data

Hire date, regular work schedule, hourly rate or salary, shift information, and anticipated lost work time to calculate indemnity exposure and benefit eligibility.

Witness and Supervisor Notes

Names and contact details of witnesses and immediate supervisors, plus initial corrective actions and whether equipment or safety procedures were involved.

Employer Certification

Signature, title, and date from an authorized employer representative certifying the accuracy of the report and indicating whether the worker returned to work.

Required Information Elements

Employee Name: Full legal name
Date of Injury: MM/DD/YYYY
Job Title: Current position
Employer Name: Legal business name
Treating Provider: Clinic or physician
Incident Location: Worksite address

Step-by-Step: Filling Out the First Report

Follow these steps to collect facts, complete the form, and route it for insurer intake to avoid delays in claim handling and benefits delivery.

  • 01
    Collect Facts: Interview worker and witnesses; document time, place, and actions.
  • 02
    Record Medical Details: Note initial treatment provider and any follow-up instructions.
  • 03
    Complete Employer Section: Provide payroll, job, and supervisor information.
  • 04
    Submit to Insurer: Send via insurer portal, email, or state form per policy.

Configuring an Online Intake Workflow

Map each field to capture, validation, and routing rules to support automated claim creation and reduce manual rework.

Field Validation Rule | Routing
Date of Injury MM/DD/YYYY | Auto-validate
Employee ID Alphanumeric | Auto-match HR
Medical Provider Required | Notify medical case manager
Supervisor Approval Signature required | Send to HR

Where to File or Send the First Report

The completed report should be routed to the insurer/TPA, kept in employer records, and shared with medical case managers and regulatory bodies as required.

  • Insurer/TPA: Primary recipient to open the claim and assign adjuster.
  • Employer File: Employer retains a copy for payroll and return-to-work tracking.
  • State Agency: When required by state law, submit the state-specific incident report.
  • Medical Provider: Share for treatment history and ongoing care coordination.

Digital Signing and Submission Options

Electronic completion and submission are accepted in most jurisdictions if they meet ESIGN/UETA requirements and internal privacy policies.

  • PDF / DOCX: Common editable formats
  • eSignature: ESIGN/UETA compliant
  • Secure Upload: Encrypted at rest

Typical Timelines and Reporting Expectations

Reporting windows vary by employer policy, insurer contract, and state law; timely submission reduces penalties and speeds medical authorization.

Immediate Notification:

Report to employer as soon as possible

Insurer Intake:

Submit to insurer promptly; many employers require within 24–72 hours

State Filing:

Some states require a separate state form or notice

Medical Authorization:

Initial treatment authorization issued after report

Claim Opening:

Insurer assigns claim number and adjuster

Common Mistakes to Avoid

  • Incomplete incident descriptions that obscure causation
  • Incorrect or missing pay-rate data affecting benefit estimates
  • Delays in sending the report to the insurer or state
  • Using unofficial or outdated form versions

Risks of an Incorrect or Late First Report

Benefit Delays: Delayed payments
Penalties: State fines possible
Claim Denial: Coverage disputes
Increased Reserves: Higher insurer reserves
Legal Exposure: Greater litigation risk
Audit Issues: Recordkeeping violations

eSignature Pricing Comparison for Filing and Signing First Reports

Pricing and feature availability vary by vendor and plan. The table below lists starting prices and common features to consider for secure signing and HIPAA-capable workflows.

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 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
Envelope Cap No cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

FAQs — Common Questions About the First Report

Answers to frequent questions about completion, e-signatures, corrections, and recordkeeping for the Workers Compensation First Report of Injury or Illness.


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