Fill - Free fillable First Report of Injury (Colorado DORA) PDF form

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

“Clear Entire Form” button

Clears all information at once

“Check Box”

Click in box

“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?

□ 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

What was the employee doing just before the accident occurred?

Tell us how the injury occurred

What object or substance directly harmed the employee?

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?

(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

;

What was the employee doing

just before the accident occurred?

; What happened?

; What object or substance directly harmed the employee?

)

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.”

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