Reports

 

 Form

 Description

 Formats

 Employer's First Report of Injury

Form #: WC1
(Rev. 01/06)

This report is filed in all instances where the employer has received notice or knowledge of a work related injury or occupational disease.  The report may only be filed by the employer or employer representative. 

Please Note: This form is required to be filed electronically pursuant to Rule 5-1(C). See Rule 5-1(D) for exemptions from electronic filing.

  PDF

 MS Word

Supplemental Report of
Return to Work

Form #WC12
(Rev. 07/03)

This report is used by employers and claimants to provide the insurer with return to work information.

 PDF

 MS Word  

 Monthly Summary

Form #WC98
(Rev. 01/06)

 The Division requires that this report be filed by the insurer or self-insured employer, to report medical-only injuries or exposures to injurious substances (as defined by Director by rule), which did not result in a fatality, permanent impairment or time loss from work in excess of 3 days or 3 shifts.

  PDF 

 MS Word