Fillable Form 8wc - Employer'S First Report Of Occupational Injury Or Disease printable pdf download

This form must be printed and faxed to the NHADA Workers' Compensation Trust at 224-8126.

EMPLOYER’S FIRST REPORT OF

OCCUPATIONAL INJURY OR DISEASE (Form 8WC)

The New Hampshire Automobile Dealers Association

Return to:

PO Box 2337, 507 South Street

Concord, NH 03302-2337

(800) 852-3372 fax: 224-8126

IMPORTANT; Every employer shall file this report as soon as possible after knowledge of any occupational injury or disease to an employee, but no later than five

days thereafter. Notice of disability of four or more days shall be filed no later than seven days after date of injury on Supplemental Report Form No. 13WCA. Failure

to comply with any or all of the above carries a civil penalty of up to $2,500.00. RSA 281A:53.

PLEASE TYPE OR PRINT. ILLEGIBLE OR INCOMPLETE FORMS WILL BE RETURNED.

1. Name of injured:

First

Middle Initial

Last

2. DOB:

3. Age:

4. Male ____

5. SS No.:

Female ____

6. Address:

No. & St.

City/Town

7. State:

8. Zip Code:

9. Tel. No.:

10. Is there on file a N.H. Youth

11. Occupation when injured:

12. Was this his/her regular occupation?

13. Wages per hr.:

14. No. hrs. worked per day:

Employment Certificate?:

If not, state regular occupation:

15. No. days worked per week:

16. Average Weekly Earnings:

17. Was injured hired in N.H.?

18. Date employment began:

19. Date & Time of Injury:

20. Date disability began:

21. Was injured paid in

22. Date supervisor/employer

23. Name of Person notified:

24. Location/Jobsite where accident occured:

full for this day?

was first notified:

25. Describe fully how accident occurred and describe what employee was doing when injured:

26. Name of witness(es):

27. Part(s) of body injured:

28. Estimated length of disability:

29. Has injured returned to work?

30. If so, what date?

31. At what occupation or job?

32. Returned at: Full Duty: ___________

Alternative/Light Duty: ____________

33. Equipment causing injury:

34. Were safeguards in place?

35. Was accident caused by injured’s failure to use safeguards or

follow regulations?

36. Initial Treatment: (check those that apply)

No medical treatment: ____

Care provide by Employer only (on-site): ____

Emergency care: ____

Hospitalized: ____

Other: (Outpatient): ____

(Clinic): ____

(Office Visit): ____

(Other-explain): _______________________________________________________________________________________________________

37. Name of treating physician:

Name of treating hospital:

38. Has injured died? If so, what date?

39. Legal Business Name and/or D/B/A or Leasing Company Name:

40. Employers Federal ID:

41. If leased or temporary worker, client’s business name:

42. Business Address of No. 39 above:

43. City/State:

44. Zip:

45. Telephone Number:

46. Insurance Co. (not agent) or Self Insured Group:

47. Managed Care Program? Y or N. If yes, name Provider:

48. No. of Employees: Full-time:

Part-time:

49. Is there a Written Safety Program in force?

50. Is there an active Safety Committee?

51. Business SIC Code

52. Type or Nature of Business in N.H.:

53. If report sent by Insurance Agency, state name:

54. Employer Signature:

55. Printed/Typed Name and Official Title:

56. Employee Signature (whenever possible):

57. Date of this report:

Form 8WC (7-95)

White – Labor Department

Canary – Insurance Claims Office

Pink – Employer’s Copy

Form 8wc - Employer'S First Report Of Occupational Injury Or Disease

Related Articles

Related forms

Related Categories