Form 8awca - Notice Of Accidental Injury Or Occupational Disease

This form must be printed and sent to the NH Department of Labor.

THE STATE OF NEW HAMPHSIRE

DEPARTMENT OF LABOR

SPAULDING BUILDING

95 PLEASANT STREET

CONCORD, NEW HAMPSHIRE

NOTICE OF ACCIDENTAL INJURY OR OCCUPATIONAL DISEASE 8aWCA

(Please print or type)

To_____________________________________________________________________ Phone #______________________

(Name of Employer)

____________________________________________________________________________________________________

(Business Name and Address)

IN ACCORDANCE WITH RSA 281-A:20, This is to notify you that an injury occurred.

______________________________________________________________________ SS #__________________________

(Name of Injured Employee)

_____________________________________________________________Daytime Phone #_________________________

(Address of Injured Employee)

____________________________________________________________________________________________________

(Date of Accident or First Treatment)

____________________________________________________________________________________________________

(Place Accident Happened)

Describe your injury or disease, and how it happened. Identify the body part(s) affected._____________________________

____________________________________________________________________________________________________

I have been unable to work since my injury.

__________

Yes

I have incurred the following medical bills. ______________________________ ___________________ ______________

Name of Doctor

Dates of Service

Amount

______________________________ ___________________ ______________

Name of Hospital

Dates of Service

Amount

______________________________ ___________________ ______________

Other

Dates of Service

Amount

__________________________________________________

_____________________________________________

(Employer’s Signature)

(Employee’s Signature)

__________________________________________________

_____________________________________________

(Date)

This form can be returned to DOL with or without employer’s signature.

NOTICE TO EMPLOYER

YOU MUST FILE AN EMPLOYER’S FIRST REPORT, Form No. 8WC, WITH THE LABOR COMMISSIONER AND

THE NEAREST CLAIMS OFFICE OF YOUR INSURANCE CARRIER, AS SOON AS POSSIBLE AFTER

ACQUIRING KNOWLEDGE OF THE OCCURRENCE OF AN OCCUPATIONAL INJURY OR DISEASE TO

ONE OF YOUR EMPLOYEES OR UPON PRESENTATION OF THIS NOTICE BY HIM, BUT NO LATER

THAN FIVE DAYS THEREAFTER. FAILURE TO COMPLY CARRIES AN AUTOMATIC CIVIL PENALTY

OF UP TO $2500. (RSA 281-A:53)

Form No. 8aWCA (Rev. 08/01)

Employer’s Copy – White

Employee’s Copy - Pink

Form 8awca - Notice Of Accidental Injury Or Occupational Disease - 2001

Related Articles

Related forms

Related Categories