Employers First Report Of Injury Or Illness {DWC-1}

DWC FORM-1 (Employer's First Report of Injury or Illness) The employer is required to file an Employer's First Report of Injury or Illness [DWC FORM -1 (Rev. 10/05)] with the injured worker's insurance carrier, and the injured claimant or the claimant's representative within 8 days after the employee's absence from work or receipt of notice of occupational disease. The Employer's First Report of Injury or Illness provides information on the claimant, employer, insurance carrier and medical practitioner necessary to begin the claims process. Details of the claimant's employment and circumstances surrounding the injury or illness are also requested. Send the specified copies to your Workers' Compensation Insurance Carrier and the injured employee. *Employers - Do not send this form to the Texas Department of Insurance, Division of Workers' Compensation, unless the Division specifically requests a direct filing. [Workers' Compensation Rule 120.2] American LegalNet, Inc. www.USCourtForms.com DWC FORM-1 (Rev. 10/05) Page 1 DIVISION OF WORKERS' COMPENSATION INSTRUCTIONS FOR EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS (DWC FORM-1) Type (or print in black ink) each item on this form. Failure to complete each item may delay the processing of the injury claim. Article 8308 - 5.05, Texas Workers' Compensation Act, requires an Employer's First Report of Injury or Illness (DWC FORM - 1 (Rev. 10/05) to be filed with the Workers' Compensation Insurance Carrier not later than the eighth day after the receipt of notice of occupational disease, or the employee's first day of absence from work due to injury or death. A copy of this report must be sent to the employee or the employee's representative. For purposes of this section, a report is filed when personally delivered, or postmarked. Send the specified copies to your Workers' Compensation Insurance Carrier and the injured employee. *Employers - Do not send this form to the Texas Department of Insurance, Division of Workers' Compensation, unless the Division specifically requests a direct filing. If a report has not been received by the carrier, the employer has the burden of proving that the report was filed within the required time frame. The employer has the burden of proving that good cause existed if the employer failed to file the report on time. An employer who fails to file the report without good cause may be assessed an administrative penalty not to exceed $500.00. An employer who fails to file the report without good cause waives the right to reimbursement of voluntary benefits even if no administrative penalty is assessed. Once the employer has completed all information pertaining to the injury the employer should maintain the copy of this report to serve as the Employer's Record of Injury required by Article 8308 -5.04. Send the specified copies to your Workers' Compensation Insurance Carrier and the injured employee. *Employers - Do not send this form to the Texas Department of Insurance, Division of Workers' Compensation, unless the Division specifically requests a direct filing. The Division's Health and Safety will use data from this report for the Job Safety Information System established in Article 8308 - 7.03 of the Texas Workers' Compensation Act. This report may not be considered admission or evidence against the employer or the insurance carrier in any proceeding before the Division or a court in which facts set out in the report are contradicted by the employer or insurance carrier. "SPECIAL INSTRUCTIONS FOR CERTAIN ITEMS" Items 2,7,8: Item 4: Article 8308 - 2.13(e), Texas Workers' Compensation Act requires the Division to maintain information as to the race, ethnicity and sex on every compensable injury. This information will be maintained for non-discriminatory statistical use. If no home phone, please provide a phone number where the employee can be reached. Items 5,15,17, 26,29,30: Enter data in month, day, year format. Example: 08-13-54. Item 18: Item 19: Item 20: Item 22: Item 24: Items 32,33: Item 37: Item 45: Item 46: List nature of accident or exposure, e.g., fall from scaffold, contact with radiation, etc. If occupational disease, so state. List specific body part, e.g., chin, right leg, forehead, left upper arm, etc. If more than one body part is affected, list each part. Describe in detail (1) the events leading up to the injury/illness, (2) the actual injury, e.g., cut left forearm, broken right foot, etc., and (3) the reason(s) why accident/injury occurred. Use an additional sheet of paper if necessary. State the exact work-site location of the injury, e.g., construction site, office area, storage area, etc. List object, substance, or exposure that directly inflicted the injury or illness, e.g., floor, hammer, chemicals, etc. Enter date in month-year format. Example: 02-56. Enter the number of days or hours that make up a full work week for your employees. Enter the 6-digit North American Industry Classification System (NAICS) Code of the employer. The primary code is the code which appears in block 5 of Form C-3, "Employer's Quarterly Report" to the Texas Workforce Commission. For companies with a single NAICS code, the specific code is the same as the primary code. For companies with multiple NAICS codes, enter the code that identifies the specific business, activity, or work-site location the employee was working in at the time of the injury. This may or may not be the same as the primary code. American LegalNet, Inc. www.USCourtForms.com DWC FORM-1 (Rev. 10/05) Page 2 DIVISION OF WORKERS' COMPENSATION Send the specified copies to your Workers' Compensation Insurance Carrier and the injured employee. *Employers - Do not send this form to the Texas Department of Insurance, Division of Workers' Compensation, Unless the Division specifically requests a direct filling. CLAIM # ______________________________________ CARRIER'S CLAIM # EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS 1. Name (Last, First, M.I.) 2. Sex 15. Date of Injury (m-d-y) 16. Time of Injury : am pm F 3. Social Security Number 4. Home Phone ( ) M 18. Nature of Injury* 17. Date Lost Time Began (m-d-y) - 5. Date of Birth (m-d-y) - 19. Part of Body Injured or Exposed* 6. Does the Employee Speak English? YES 7. Race Black 9. Mailing Address NO If No, Specify Language 20. How and Why Injury/Illness Occurred* White Asian Street or P.O. Box 8. Ethnicity Hispanic Other Native American 21. Was employee doing his YES regular job? NO 22. Worksite Loca