First Report of Injury Form
Step 1 of 10
Step 1: Employer Information
Employer Name
*
Employer Address
*
City
*
State
*
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PW
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
*
Check here if this is a public school system
What portion of employee’s wages are funded by the local government?
%
Is the accident address different from employer address?
Yes
Accident Location Name
(if different from above)
Accident Address
City
State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PW
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
Policy Number
Employer Contact name
*
Employer Contact Email Address
*
Employer Contact Phone
*
Submit & Continue to Step 2
Directions:
Please complete employer information in Step 1.
*
denotes required items.
Your session ID is 57f04b1719a77f8d053549451aa80b2de643cbd3