First Injury Report Fill Online, Printable, Fillable, Blank pdfFiller
First Report Of Injury Form. Web the employer is responsible for accurately completing all sections of this form when an employee is injured. Part of body injured or exposed* 6.
First Injury Report Fill Online, Printable, Fillable, Blank pdfFiller
Include the sequence of events and name any objects or substance that directly injured the employee or made the employee ill. Send the original form to the claim administrator for the insurance company who provided insurance coverage on the date of the occurrence. Web the employer is responsible for accurately completing all sections of this form when an employee is injured. This helps us to identify and correct hazards before they cause serious injuries. Web the use of this form is required under the provisions of the tennessee workers'compensation law and must be completed and filed with your insurance carrier immediately after notice of injury. Web describe how the injury or illness/abnormal health condition occurred. Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. Does the employee speak english? Department of labor (see instructions on reverse) office of workers' compensation programs omb no. Home phone ( ) 5.
Web employer's first report of injury. Web deaths and serious injuries must be reported to the department within 48 hours. Home phone ( ) 5. Web employer's first report of injury. Include the sequence of events and name any objects or substance that directly injured the employee or made the employee ill. Date and time of accident (mm/dd/yyyy) (hh:mm am/pm) 4. Web the employer is responsible for accurately completing all sections of this form when an employee is injured. This can be done via telephone, facsimile or electronic transmission, to be followed by the froi form within seven days of the occurrence. The employer must also send a. You may file your first report of injury (form 101), your monthly payment reports (form 107) and a request for extension of time online using the first report of injury management system. Web the use of this form is required under the provisions of the tennessee workers'compensation law and must be completed and filed with your insurance carrier immediately after notice of injury.
