Colorado First Report of Injury Form

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Instructions for Completing the
First Report of Injury
Please read all pages
This form is “fillable.” That means you can type the information onto
the form from your computer and print the form. You will not be able
to save the form onto your computer’s hard drive.
When you open the form, click in the “Employee’s Name” box (field),
complete the information, and use the tab key to navigate to the next
field. Do not use the Enter key; pressing the Enter key will only page
down. Each field has been limited. This means that you cannot
continue to type information into a field if it doesn’t fit into the space
provided.
Use numbers only to fill in the fields for Social Security #, phone
numbers and dollar amounts. If a dollar amount contains cents, do
type the period. To fill in a check box, click inside the box with your
mouse. Some check boxes require you to select only one answer;
you cannot check both. The “Injury Description”, “Name of Witness”,
and “Name of Doctor” fields have a gray border to indicate how
many lines you have to type in. Use the tab key to navigate to the
next field.
To clear or delete all the information you have typed onto the form,
click on the red “Clear Entire Form” button. To change the information
in one field, use the backspace or delete key.
1
“Clear Entire Form” button
Clears all information at once
“Check Box”
Click in box
2
“Check Boxes with one selection”
Check only one
“Gray Border”
Enter information and tab to next field
3
See instructions on reverse side before
completing form.
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
Back to Instructions
Employee’s name (first, middle, last)
Social Security #
/
City
Marital status
□ Married □ Separated
□ Single
□ Unknown
/
Occupation
Date of hire
Employer’s name
/
Employment status
□ Full time
□ Part time
□ Other
□ Unknown
Employer’s phone #
(
)
State
Zip code
/
Employer’s Federal ID #
Employer’s mailing address
City
Average weekly wage at time
of injury
$___________________
Check box if employee receives
□ Tips
□ Meals
□ Room □ Health insurance
Were full wages paid for the DOI?
□ Yes □ No
Injury time
Last day worked
(see instructions on reverse side)
/
For
Division
use only
SOI
POB
NOI
Check if these benefits are included in AWW
Coder
□ Tips
□ Meals
□ Room
□ Health insurance
Are wages continued per C.R.S. 8-42-124? 1
□ Yes □ No
Date employer
Date disability
Date returned to
notified
began
work
Is the employer self-insured?
□ Yes □ No
Injury/Illness Time employee
began work
date
____ ___ □ a.m. ____ ___□ a.m.
/ /
/
/
/
/
/
____ ___ □ p.m. ____ ___ □ p.m.
(See instructions
on reverse side)
□ unknown
Did injury cause
Name, relationship, and address of closest dependent if injury caused
If so,
death?
death
date of death
□ Yes
□ No
/
OSHA
Log #
Employee’s home phone #
(
)
State
Zip code
□ Male
□ Female
Employee’s street address
Birth date
Clear Entire Form
EMPLOYER’S FIRST REPORT OF INJURY
/
/
/
Injury occurred because of
□ Intoxication
□ Safety violation
□ Not applicable
Tell us the nature of the injury/illness2
Tell us the part of body that was affected
What was the employee doing just before the accident occurred?3
Tell us how the injury occurred4
Did injury occur
on premises?
□ Yes
What object or substance directly harmed the employee? 5
Injury site address/ 9-digit zip code
Initial treatment (check one)
Was the employee hospitalized
overnight as an in-patient?
□ Emergency room □ Yes □ No
□ None
□ Hospital >24 hrs
□ Minor on-site
□ Clinic/hospital
Name of employer representative notified
□ No
Names of witnesses
Name and address of treating doctor or other health care professional
Completed by (name)
Name and address of facility where treated
Title
Phone #
(
)
Date completed
/
/
The following is to be completed by the insurer prior to filing with the Division of Workers’ Compensation.
Name of insurance company
Address
Name of third party administrator (if applicable)
Address
Adjuster name
Adjuster phone #
Policy #
Carrier claim #
Date insurer received first report
/
WC 1 Rev 01/06
/
Block #
Adj. Code
INSTRUCTIONS
This form contains all items requested on OSHA Form No. 301,
“Injuries & Illnesses Incident Report”
General
•
All injuries no matter how trivial must be reported to your insurance company.
•
All injuries or occupational diseases which result in lost time from work in excess of three shifts or calendar days, or in
permanent physical impairment, must be reported to your insurance carrier on this form within ten days after notice or
knowledge of the injury or disease. Fatalities must be reported to your insurance carrier immediately.
•
Forms should be typed or printed legibly.
•
All questions must be answered completely to meet requirements of the Colorado Workers’ Compensation Act and to conform to
the OSHA requirements for Form No. 301.
•
The employer has the right in the first instance, to select the physician who attends the injured employee.
Calculation of Average Weekly Wage
•
Determine the weekly wage rate.
•
Add the average weekly amount of any overtime wages, tips or commissions.
•
Add the average weekly value of any board, rent, housing, or lodging provided by the employer if the employer will not be
paying such benefit during the period of disability.
•
If the employee is covered by group health insurance and the employer does not continue the employee’s health insurance
coverage during the period of disability, add the employee’s cost of conversion to a similar or lesser insurance plan and include
this cost in the average weekly wage computation.
•
Compute the total from the above categories and insert in the Average weekly wage at time of injury field.
Injury Date Information
In the case of an occupational disease, use the date of the last injurious exposure.
Notes
Are Wages continued per C.R.S. 8-42-124?1
(Subject to application with and approval of the Director of the Colorado Division of Workers’ Compensation)
1
Any employer who, by separate agreement, working agreement, contract of hire, or any other procedure, continues to pay a sum
in excess of the temporary total disability benefits to an employee temporarily disabled as a result of a work related injury or
disease, and has not charged the employee with any earned vacation leave, sick leave, or other similar benefits, shall be
reimbursed if insured by an insurance carrier or shall take credit if self-insured, to the extent of all moneys that such employee
may be eligible to receive as compensation for temporary partial or temporary total disability subject to the approval of the
Director of the Colorado Division of Workers’ Compensation.
Injury Description (Tell us the part of body that was affected. Tell us the nature of the injury/illness 2; What was the employee doing
just before the accident occurred? 3; What happened? 4; What object or substance directly harmed the employee?5)
2
3
4
5
Be more specific than “”hurt”, “pain”, or “sore.” Examples: “strained back”; “chemical burn, hand”; “carpal tunnel syndrome.”
Describe the activity, as well as the tools, equipment or material the employee was using. Be specific. Examples: “climbing a
ladder while carrying roofing materials”; “spraying chlorine from hand sprayer”; or “daily computer key-entry.”
Tell us how the injury occurred. Examples: “When ladder slipped on wet floor, worker fell 20 feet”; “Worker was sprayed with
chlorine when gasket broke during replacement”; “Worker developed soreness in wrist over time.”
Examples: “concrete floor”; “chlorine”; “radial arm saw.” If this question does not apply to the incident, leave it blank
Notices
You are hereby notified that if a child support obligation is owed, compensation benefits may be attached and payment of the
child support obligation may be withheld and forwarded to the obligee pursuant to sections 8-42-124 and 26-13-122(4), C.R.S.
YOU ARE FURTHER NOTIFIED that you must provide written notice of any award for social security, pension, disability or
other source of income that might reduce your compensation benefits. This notice must be sent to the insurance carrier or
self-insured employer within 20 days after learning of the payment or award. Failure to report may result in suspension of
your benefits pursuant to section 8-42-113.5, C.R.S.
C.R.S. Section 10-1-128(6) (a) states: “It is unlawful to knowingly provide false, incomplete, or misleading facts or information
to an insurance company for the purposes of defrauding or attempting to defraud the company. Penalties may include
imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who
knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of
defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from
insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.”
WC 1 Rev 01/06