The report form that initiates the claim process is a compensation court Form 2, the EMPLOYERS FIRST NOTICE OF INJURY. If you do not have a blank form, there is a link to the Workers Compensation Court website contained on the Workers Comp. Form 2 page.

That site has a blank Form 2 you can use. This form can be filled in and copied to your printer or the blank form can be printed and filled in later. The completed form can then be mailed or faxed to Claims & Risk Services.

Remember, this is the EMPLOYERS report and not the employees report. It is up to the EMPLOYER to verify the facts and report the claim. The form should be completed in it’s entirety. We must have the correct address, phone number and social security number of the injured employee. The average weekly wage should include any overtime and should cover the 52 weeks prior to the date of injury.

The Date of Accident may be the day of a single incident accident. In the case of a cumulative trauma it would be the first day it was reported to you or the date of last exposure if the employee is no longer working. If the employee lost no time from work, put “No Lost Time” in the block for Last Date Employee Worked.

Be as specific as possible in listing the type of injury, body part and how the accident happened. If the description of accident blank does not have enough room, continue on a separate sheet.

If you are insured with a company or Own Risk Group, give us the full name and policy or group number. If you are a self insured employer, enter OWN RISK and give us your Own Risk Number assigned to you by the Court.

Give us the full name, address and ZIP code of your company. Date and sign the form and print the name of the person signing. We will review the form for accuracy and send it to the Workers Compensation Court.

Send the report to us as soon as possible. Do not wait for the doctor to send you a medical report or bill. We will request those from the doctor. The sooner we get the report, the sooner we can give you and your employee the service you deserve.

Call us if you have any questions or if we can be of assistance.