EMPLOYER'S FIRST REPORT OF INJURY OR DISEASE
Department of Workforce Development
Worker's Compensation Division
P.O. Box 7901, Madison, WI 53707
An employer shall report immediately
I. EMPLOYEE DATA
Employee Name (First, Middle, Last)
Social Security Number
Employee Home Phone No
Employee Street Address
Date of Hire
County and State Where Accident or Exposure Occurred?
II. EMPLOYER DATA
WI Unemployment Ins. Acct No.14. Federal ID Number
Nature of Business (Specific Product)
Employer Mailing Address
Name of Worker's Compensation Insurance Co. or Self-Insured Employer
Name and Address of Third Pary Administrator (TPA) Used by the insurance Company or Self-Insured Employer
Wage at Time of Injury
Specifiy per hr, wk, mo, yr, etc
In Addition to Wages,
Check Box(es) if
No. of Meals/wk
No. of Days/wk
Avg Weekly Amt $
Is Worker Paid for Overtime?
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. Exluding Overtime
Hours Per Day
Hours Per Week
Days Per Week
Employer's Usual Work Schedule When Injured:
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?
If yes, how many?
# of Full-Time Employees Doing Same Type Of Work:
Time of Injury
Last Day Worked
Date Employer Notified
Date Returned to Work
Est Date of Return
Did Injury Cause Death?
Date of Death
Was This a Lost Time or Other Compensable Injury?
Did Injury Occur Because of:
Failure to Use Security Devices
Failure to Obey Rules
Was Employee Treated in an Emergency Room?
Was Employee Hospitalized Overnight as an In-Patient?
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 Happended 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