Explanation of Compliance Requirement for First Report
Employer must complete all relevant sections on this form and submit it to the employers worker's compensation insurance carrier or third party administrator within seven (7) days after the date of a work related injury which causes permanent or temporary disability resulting in compensation for lost time. The employers insurance carrier or third party administrator may request that this form also be used to immediately report any injury requiring medical treatment, even though it does not involve lost work time.
For any work injury resulting in a fatality, the employer must also submit this form directly to the Department of Workforce Development within 24 hours of the fatality.
An employer exempt from the duty to insure under s. 102.28, Wis. Stats., and an insurance carrier administering claims for an insured employer are required to submit this form to the Department or Workforce Development within 14 days of the date of work injury.
In order to accurately administer claims, each of the following sections of this form must be completed. The First Report of Injury will be returned to sender if the mandatory information is not provided.
Employee Section: Provide all requested information to identify the injured employee. If an employee has multiple dates of employment, the "Date of Hire" is the date the employee was hired for the job on which he or she was injured.
Employer Section: Provide all requested information to identify the injured worker's employer at the time of injury. Provide the name and Federal Employer Identification Number (FEIN) for the insurance carrier or self-insured employer responsible for the worker's compensation expenses for this injury. Also identify the third part claim administrator if one is used for this claim.
Wage Information Section: Provide the information requested regarding the injured employee's wage and hours worked for the job being performed at the time of injury.
Injury Information Section: Provide information regarding the date and time of injury. Provide a detailed description of the injury, including part of body injured, the specific nature of the injury (i.e. fracture, strain, concussion, burn, etc) and the use of any objects or tools (i.e. saw, ladder, vehicle, etc) that may have caused the injury. Provide the name of the person preparing this report and the telephone number at which they may be reached if additional information is needed.