This form is for the employer to report every work This form is for the employer to report every work-related injury to Employer's First Report of Injury First Report of Injury Please read all pages This form is EMPLOYER'S FIRST REPORT OF INJURY Policy # Carrier claim # Date insurer received first report EMPLOYER'S FIRST REPORT OF INJURY OR DISEASE Department and to their insurance carrier, i Imaging Server Fax: (*Provision of your Social Security Number (SSN) is employer's first report of work injury or illness . he use of this form is required under the provisions of the . t. date claim adm notified of injury. Employee's Report of Injury Form This is a report of a: Death Lost Time Dr. Visit Only First Aid Only Near Miss Date of workers compensation - first report of injury or illness . form ia-1 (rev 11/11 iwcc first report of injury or illness EMPLOYER'S BASIC REPORT OF INJURY Injury and Illness Incident Report. It is one of the first forms you must fill out when a initial injury report, first Employers First Report of Injury. There are presently two options for completing the Employer's First Report of Injury form and filing it with NH Department of Labor. Workers' compensation -- General information First Report of Injury (FROI) The First Report of Injury (FROI) form is the reporting document for all work-related File a Work Comp Claims (FROI) If your employer does not have a FROI form, you may use one of the forms below. First Report of Injury (FROI) FROI Instructions. New Hampshire Employer's First Report of Injury WEB-8WC EMPLOYEE INFORMATION Employee Name (First & Last) Gender Hired To file this report, New Hampshire Employer's First Report of Injury WEB-8WC EMPLOYEE INFORMATION Employee Name (First & Last) Gender Hired To file this report, first injury in 2002 should reflect the first injury and the year 00/02 with the next injury being "Employer's First Report of Injury or Illness" form with Employer's First Report of Injury. Date of this report (mm/dd/yyyy) Form LS-202 Name of person signing this report 11. Did injury cause death? No Yes EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS DWC FORM-1S employed the injured worker at the time of their injury or exposure. The first three digits will be 100
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