Fillable Printable Employer's First Report of Injury or Disease - Wisconsin

Employer's First Report of Injury or Disease - Wisconsin

EMPLOYER’S FIRST REPORT OF INJURY OR DISEASE

Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an

information processing delay.

Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes].

(Please read the instructions on page 2 for completing this form)

Employee Name (First, Middle, Last)

Social Security Number

- -

Sex

M F

Employee Home Telephone No.

( ) -

Employee Street Address

City

State

Zip Code

Occupation

Birthdate

Date of Hire

County and State Where Accident or Exposure Occurred?

Employer Name

WI Unemployment Ins. Acct No.

Self-Insured?

Yes No

Nature of Business (Specific Product)

Employer Mailing Address

City

State

Zip Code

Employer FEIN

Name of Worker’s Compensation Insurance Co. or Self-Insured Employer

Insurer FEIN

Name and Address of Third Party Administrator (TPA) Used by the Insurance Company or Self-Insured Employer

TPA FEIN

Wage at Time of Injury

Specify per hr., wk., mo., yr., etc.

Per:

In Addition to Wages, Meals No. of Meals/wk.

Check Box(es) if

Room No. of Days/wk

Employee Received:

Tips Avg. Weekly Amt. $

Is Worker Paid for Overtime? Yes No If Yes, After How Many Hours of Work Per Week?

For the 52 Week Period Prior to the Week the Injury Occurred, Report Below the Number of Weeks Worked in the Same Kind of Work,

and the Total Wages, Salary, Commission and Bonus or Premium Earned for Such Weeks.

No. of Weeks:

Gross Amount Excluding Tips: $

If Piece-Work, No. of Hrs. Excluding Overtime:

Start Time

Hours Per Day Hours Per Week Days Per Week

Employee’s Usual Work Schedule When Injured:

: AM PM

Employer’s Usual Full-Time Schedule for This

Type of Work at Time of Employee’s Injury:

Part-Time

Employment

Information:

Are there Other Part-Time Workers Doing the Same Work

With the Same Schedule?

Yes No If

how man

Number of Full-Time Employees Doing The

Same Type Of Work:

Injury Date

Time of Injury

: AM : PM

Last Day Worked

Date Employer Notified

Date Returned to Work

Estimated Date of Return

Did Injury Cause Death?

Yes No

Date of Death

Was This a Lost Time or Other

Compensable Injury?

Yes No

Did Injury Occur Because of:

Substance Failure to Use Failure to

Abuse Safety Devices Obey Rules

Was Employee Treated in an Emergency Room? Yes No Was Employee Hospitalized Overnight as an In-Patient? Yes No

Name and Address of Treating Practitioner and Hospital:

Case Number from the OSHA Log:

Injury Description - Describe Activities of Employee When Injury or Illness Occurred and What Tools, Machinery, Objects, Chemicals, Etc. Were

Involved.

What Happened to Cause This Injury or Illness? (Describe How The Injury Occurred)

What Was The Injury or Illness? (State the Part of Body Affected and How It Was Affected)

Report Prepared By

Work Phone Number

( ) -

Position

Date Signed

WKC-12 (R. 07/2014)

SEND REPORT IMMEDIATELY - DO NOT WAIT FOR MEDICAL REPORT

Department of Workforce Development

Worker’s Compensation Division

201 E. Washington Ave., Rm. C100

P.O. Box 7901

Madison, WI 53707-7901

Imaging Server Fax: (608) 260-2503

Telephone: (608) 266-1340

http://www.dwd.wisconsin.gov/wc

e-mail: [email protected]isconsin.gov

INJURY INFORMATION WAGE INFORMATION EMPLOYER EMPLOYEE

Fatal Injuries: Employers subject to ch.102, Wis. Stats., must report injuries resulting in death to the

Department and to their insurance carrier, if insured, within one day after the death of the employee.

Non-Fatal Injuries: If the injury or occupational illness results in disability beyond the three-day waiting

period, the employer, if insured, must notify its insurance carrier within 7 days after the injury or beginning

of disability. Medical-only claims are to be reported to the insurance carrier only, not the Department.

Electronic Reporting Requirement: All work-related injuries and illnesses resulting in compensable lost

time, with the exception of fatalities, must be reported electronically to the Department via EDI or Internet

by the insurance carrier or self-insured employer within 14 days of the date of injury or beginning of

disabilit

. Em

er ma

fax claims for fatal in

uries to the Ima

Fax Server number on this form.

EMPLOYER AND INSURANCE CARRIER INSTRUCTIONS

The employer must complete all relevant sections on this form and submit it to the employer’s worker’s

compensation insurance carrier or third party claim administrator within seven (7) days after the date of a

work-related injury which causes permanent or temporary disability resulting in compensation for lost time.

The employer’s insurance carrier or the third-party claim’s administrator may request that this form also be

used to immediately report any injury requiring medical treatment, even though it does not involve lost work

time.

For any work injury resulting in a fatality, the employer must also submit this form directly to the Department

of Workforce Development within 24 hours of the fatality.

An employer exempt from the duty to insure under s. 102.28, Wis. Stats., and an insurance carrier

administering claims for an insured employer are required to submit this form to the Department of Workforce

Development within 14 days of the date of work injury.

MANDATORY INFORMATION

In order to accurately administer claims, each of the following sections of this form must be

completed. The First Report of Injury will be returned to the sender if the mandatory information is not

provided.

Employee Section: Provide all requested information to identify the injured employee. If an employee has

multiple dates of employment, the “Date of Hire” is the date the employee was hired for the job on which he or

she was injured.

Employer Section: Provide all requested information to identify the injured worker’s employer at the time of

injury. Provide the name and Federal Employer Identification Number (FEIN) for the insurance carrier or self-

insured employer responsible for the worker’s compensation expenses for this injury. Also identify the third

party claim administrator, if one is used for this claim.

Wage Information Section: Provide the information requested regarding the injured employee’s wage and

hours worked for the job being performed at the time of injury.

Injury Information Section: Provide information regarding the date and time of injury. Provide a detailed

description of the injury, including part of the body injured, the specific nature of the injury (i.e., fracture, strain,

concussion, burn, etc.) and the use of any objects or tools (i.e., saw, ladder, vehicle, etc.) that may have

caused the injury. Provide the name of the person preparing this report and the telephone number at which

they may be reached, if additional information is needed. This form was designed to include information

required by OSHA on form 301. If this section is completed and retained, the employer will not have to

complete the OSHA 301 form.