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Employer's First Report of Injury or Disease

Document Number:  WKC-12-E

Description:  For the employer to report every work-related injury to its insurance company.  If an employee is out more than 3 days due to a work-related injury, or there is PPD, a copy is to be sent to the Worker's Compensation Division by the employer's worker's compensation insurance carrier, not by the employer (unless the claim is a fatality).

Comments:  This form is an electronic Microsoft Word template that can be filled out on your computer (if you have Microsoft Word).  Except for fatalities, the information on this form must be sent electronically by the employer's worker's compensation carrier to the WC Division.

Content Contact:  Don Martin

Document Attachment:  WKC-12-E (Word/109 KB)

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