Form 13 Wca - Employer'S Supplemental Report Of Injury 1989 printable pdf download

Form 13 Wca - Employer'S Supplemental Report Of Injury 1989

THE STATE OF NEW HAMPSHIRE

DEPARTMENT OF LABOR

Employer’s Supplemental Report of Injury

This report, indicating disability of an employee of four or more days, shall be filed as soon as possible after

date of knowledge of an occupational injury or disease, but no later than ten days thereafter. Consistent failure

to make this report available to the labor commissioner and the nearest claims office of your insurance carrier

carries an automatic civil penalty of up to $100.00. (RSA 281-A:53) This report shall also be submitted upon

employee’s return to work.

1. Name of Employer____________________________Employer’s Identification No.______________

(9 digit number assigned by proper Federal Agency)

2. Address___________________________________________________________________________

(No. and St.)

(City and State)

(Zip Code)

3. Insured by_________________________________________________________________________

4. Name of Employee__________________________________________________________________

(First Name)

(Middle Initial)

(Last Name)

(S.S. Number)

5. Address___________________________________________________________________________

(No. and St.)

(City and State)

(Zip Code)

6. Date of injury________________________ 20 ____________

7. Date Disability began ___________________________20 __________ A.M. _______ P.M._______

8. ___________________________________________________________________________________

(Specific dates of disability)

___________________________________________________________________________________

(Specific dates of disability)

9. Has injured returned to work?_________ if so, date and hour ____________ A.M._____ P.M._______

10. Is injured person earning same wages as before injury?_________ If not, explain__________________

___________________________________________________________________________________

Date of Report________________________________________________________________________

Signed by___________________________________

Official Title_________________________________

Tel. No.____________________________________

Form No. 13 WCA (7-89)

WHITE – LABOR DEPT.

CANARY – INSURANCE CLAIMS OFFICE

PINK – EMPLOYER’S COPY

Form 13 Wca - Employer'S Supplemental Report Of Injury 1989