First Report Injury Form. Department of labor (see instructions on reverse) office of workers' compensation programs omb no. Your insurer will report the injury to the department of labor and industry (department), when necessary.
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Web 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 employer's first report of injury. Web reporting an injury there's an injury, now what? Web this form quickly to allow your insurer time to investigate the claim. How do i report an injury? Home phone ( ) 5. In all other cases, report the injury to your employer. Name (last, first, m.i.) 2. Department of labor (see instructions on reverse) office of workers' compensation programs omb no. Your insurer will report the injury to the department of labor and industry (department), when necessary.
In all other cases, report the injury to your employer. Web this form quickly to allow your insurer time to investigate the claim. Web reporting an injury there's an injury, now what? Name (last, first, m.i.) 2. How do i report an injury? In all other cases, report the injury to your employer. Web employer's first report of injury. Department of labor (see instructions on reverse) office of workers' compensation programs omb no. Home phone ( ) 5. Web 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. Your insurer will report the injury to the department of labor and industry (department), when necessary.
