Fillable New Hampshire Employers First Report of Injury WEB-8WC (State of New Hampshire)

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New Hampshire Employers First Report of Injury WEB-8WC (State of New Hampshire)

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U.S.A. forms for State of New Hampshire

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LAB 500
New Hampshire Employer’s First Report of Injury WEB-8WC –
8WC (07/2019) To file this report, email to firstreport@dol.nh.gov Fax Number: (603)271-0126 or
Mail to: NH Department of Labor Workers’ Compensation Division 95 Pleasant St. Concord NH 03301
Submission Date: NHDOL# -
***
EMPLOYER INFORMATION
***
Employer Name Employer FEIN Industry Code
Employer Contact Name Contact Phone Number Employer Business Address
Managed Care Organization
Leased Employee? Client Company OCIP/Wrap-Up Policy? Name of policy holder
***INSURER INFORMATION***
Insurance Carrier
Insurer Type
Policy Number
Telephone Number
***SUBMITTER INFORMATION***
Submitter Name Title of Submitter Represents Telephone Number
***
EMPLOYEE INFORMATION
***
Gender
Hired Date
Hired in NH
ID Type
-
Employee ID
Date of Birth
Age
Occupation
when Injured
Employee Address Telephone Wages per Hour
Hrs per
Day
Days per
Week
Average Weekly
Earnings
***
INJURY INFORMATION
***
Injury Date / Time
Date Employer Notified
of Injury
Location/Jobsite & Business Name where accident occurred
Disability Began Date
Claim Type
Full Wages Paid on Injury Date
Accident Description
Body part Injured Cause of Injury
Nature of Injury Witness Name Witness Phone
Returned to work? If so, what date? If so, at what occupation? If so, at what duty status?
Initial Treatment Initial Treatment Date
Name of Treating Physician Name of Treating Hospital Has injured died? If so, what date
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New Hampshire Employers First Report of Injury WEB-8WC (State of New Hampshire)

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Completed 21 July 2020

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