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COLORADO (National American Insurance Company)

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1
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.
Go to Form
2
“Clear Entire Form” button
Clears all information at once
“Check Box”
Click in box
3
“Check Boxes with one selection”
Check only one
“Gray Border”
Enter information and tab to next field
WC 1 Rev 01/06
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
EMPLOYER’S FIRST REPORT OF INJURY
Employee’s name (first, middle, last) Social Security #
□ Male
□ Female
Employee’s home phone #
( )
Employee’s street address City State Zip code
OSHA
Log #
Marital status Employment status Birth date
/ /
□ Married
□ Single
□ Separated
□ Unknown
Date of hire
/ /
Occupation
□ Full time
□ Other
□ Part time
□ Unknown
For
Division
use only
Employer’s name Employer’s Federal ID # Employer’s phone #
( )
SOI
Employer’s mailing address City State Zip code
POB
Average weekly wage at time
of injury
Check box if employee receives Check if these benefits are included in AWW
NOI
$___________________
(see instructions on reverse side)
□ Tips
□ Room
□ Meals
□ Health insurance
□ Tips
□ Room
□ Meals
□ Health insurance
Coder
Is the employer self-insured?
□ Yes □ No
Were full wages paid for the DOI?
□ Yes □ No
Are wages continued per C.R.S. 8-42-124?
1
□ Yes □ No
Injury/Illness
date
/ /
(See instructions
on reverse side)
Time employee
began work
____ ___ □ a.m.
____ ___ □ p.m.
Injury time
____ ___□ a.m.
____ ___ □ p.m.
□ unknown
Last day worked
/ /
Date employer
notified
/ /
Date disability
began
/ /
Date returned to
work
/ /
Did injury cause
death?
□ Yes □ No
If so,
date of death
/ /
Name, relationship, and address of closest dependent if injury caused
death
Injury occurred because of
□ Intoxication
□ Safety violation
□ Not applicable
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
Tell us how the injury occurred
4
What object or substance directly harmed the employee?
5
Did injury occur
on premises?
Injury site address/ 9-digit zip code Initial treatment (check one) Was the employee hospitalized
overnight as an in-patient?
□ Yes □ No
□ None
□ Minor on-site
□ Clinic/hospital
□ Emergency room
□ Hospital >24 hrs
□ Yes □ No
Names of witnesses
Name of employer representative notified
Name and address of treating doctor or other health care professional
Name and address of facility where treated
Completed by (name) 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
/ /
Block # Adj. Code
See instructions on reverse side before
completing form.
Clear Entire Form
Back to Instructions
WC 1 Rev 01/06
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 Be more specific than “”hurt”, “pain”, or “sore.” Examples: “strained back”; “chemical burn, hand”; “carpal tunnel syndrome.”
3 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.”
4 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.”
5 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.”
THE EMPLOYER IS REQUIRED BY LAW TO POST THIS NOTICE
Colorado Employment Security Act (CESA), 8-74-101(2); Regulations Concerning Employment Security 7.3.1 through 7.3.5
NOTICE TO WORKERS
You have the right to be properly classified as an
employee if you meet the criteria in Colorado
Revised Statute 8-70-115. If you believe you have
been improperly classified as an independent
contractor, there is a complaint process available to
you. On the first offense, an employer may be fined
up to $5,000 per misclassified employee. To file a
complaint, call the Unemployment Insurance Audit
section at 303-318-9100 and select Option 3, or
visit www.colorado.gov/cdle/ui.
You, as an employee, are entitled to unemployment
insurance benefits if you become unemployed
through no fault of your own. Your employer
contributes to unemployment insurance and cannot
deduct this from your wages.
If you become unemployed and wish to file for
unemployment insurance benefits, go to
www.colorado.gov/cdle/ui and click on File for
Unemployment. You may also call one of the
following numbers instead:
303-318-9000
(Denver-metro area)
1-800-388-5515
502 (R 05/2011)
(Outside Denver-metro area)
TDD 303-318-9016
(Hearing Impaired Denver-metro area)
TDD 1-800-894-7730
(Hearing Impaired Outside
Denver-metro area)
If your hours of work and pay are reduced, you may
be entitled to partial unemployment benefits.
IMPORTANT NOTICE: Be sure to have your
social security number and the name and address of
your last employer available when you call to file a
claim for unemployment insurance benefits.
AVISO PARA EMPLEADOS
Usted tiene el derecho de ser propiamente
clasificado como un empleado si se cumplen los
criterios en Estatuto Revisado de Colorado 8-70-
115. Si cree que ha sido impropiamente clasificado
como un contratista independiente, hay un proceso
de queja disponible. Por la primera ofensa, un
empleador puede ser multado hasta $5,000 por cada
empleado misclasificado. Para presentar una queja,
llame a la sección de Auditoría de Seguro de
Desempleo al 303-318-9100, y marque Opción 3 o
visite www.colorado.gov/cdle/ui.
Usted, como empleado, tiene derecho a los
beneficios de seguro de desempleo si se encuentra
desempleado y no es responsable por la separación.
La compañía contribuye al seguro de desempleo y
no puede deducirlos de su sueldo.
Si se encuentra desempleado y desea reclamar los
beneficios de seguro de desempleo, vaya al sitio
www.colorado.gov/cdle/ui y haga click en en enlace
File for Unemployment. Támbien puede llamar a
los números siguentes.
303-318-9333
(Área metropolitana de Denver)
1-866-422-0402
(Fuera del área metropolitana de Denver)
TDD 303-318-9016
(Impedimento Auditivo Área de Denver)
TDD 1-800-894-7730
(Impedimento Auditivo Fuera del área
metropolitana de Denver)
Si sus horas de trabajo y pago son reducidas, usted
puede tener derecho a los beneficios parciales de
seguro de desempleo.
AVISO IMPORTANTE: Asegúrese de tener su
número de seguro social y el nombre y la dirección
de su empleo mas reciente cuando llame para
establecer su reclamo de seguro de desempleo.
Employers can download copies of this poster at www.colorado.gov/cdle/ui
, click on Forms & Publications, and then click on
Employer Forms.
Additional copies can be requested by contacting the Colorado Department of Labor and Employment, Unemployment Insurance
Program, P.O. Box 8789, Denver, Colorado 80201-8789 or by calling 303-318-9100 or 1-800-480-8299
WC50 Rev.5/99
WARNING
IF YOU ARE INJURED ON THE JOB, WRITTEN NOTICE OF
YOUR INJURY MUST BE GIVEN TO YOUR EMPLOYER
WITHIN FOUR WORKING DAYS AFTER THE ACCIDENT,
PURSUANT TO SECTION 8-43-102(1) AND (1.5),
COLORADO REVISED STATUTES.
IF THE INJURY RESULTS FROM YOUR USE OF ALCOHOL
OR CONTROLLED SUBSTANCES, YOUR WORKERS’
COMPENSATION DISABILITY BENEFITS MAY BE REDUCED
BY ONE-HALF IN ACCORDANCE WITH SECTION
8-42-112.5, COLORADO REVISED STATUTES.
WC50 Rev.5/99
AVISO
SI SE LASTIMA EN EL TRABAJO, DEBE DARLE UN AVISO
POR ESCRITO A SU EMPLEADOR DENTRO DE CUATRO
DÍAS LABORABLES DEL ACCIDENTE, SEGÚN A LA
SECCIÓN DE LOS ESTATUOS REVISADOS DE COLORADO
8-43-102(1) Y (1.5).
SI EL ACCIDENTE RESULTA DEBIDO AL USO DE ALCOHOL
O UNA SUSTANCIA CONTROLADA, SUS BENEFICIOS DE
LA INCAPACIDAD DE LA COMPENSACIÓN DE LOS
TRABAJADORES PUEDEN SER REDUCIDOS POR UN MEDIO
EN ACUERDO DE LA SECCIÓN DE LOS ESTATUOS
REVISADOS DE COLORADO 8-42-112.5.
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COLORADO (National American Insurance Company)

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Completed 29 July 2021

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