Reports
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Form
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Description
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Employer’s
First Report of Injury
Form #: WC1
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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. |
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Final
Payment Notice
Form
#WC25
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This report is filed after all compensation issues have been resolved by
final admission, final order or stipulation and must be filed 60 days
after the claim is closed. The information on this form captures total
cost of claims for statistical reporting of trends and for reports to
the legislature. |
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Supplemental
Report of
Return to Work
Form
#WC12
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This report is used by employers and
claimants to provide the insurer with “return to work” information.
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Monthly Summary
Form #WC98
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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. |
