Filling out Worker's Comp Injury form?

Be careful! Full time doesn't mean permanent and if you suspect a fake injury you had better list it here or forever hold your peace! Some instructions on reporting and form filling out designed especially for our State Fund policy holders, but also applicable to everybody else. Click HERE for a copy of the State form #3067and additional special instructions in Adobe .pdf format..

What to do when your employee becomes injured:

B. Complete "Employers Report of Occupational Injury or Illness" form 3067. Try to fill out the form as completely as possible. Be sure to include your employee's Date of Birth, Wages, Social Security Number and Date of Injury. List the names and addresses of any witnesses on a separate page. The employee does not see this form.

C. Send the original and one copy to your local State Fund Office. If you reported the claim via the Claims Reporting Center, a copy of the Employer's Report of Occupational Injury will be sent to you. If you do not receive it within one week, contact the Reporting Center to follow up.

D. Provide the employee with the "Employee's Claim Form" (form #3301-DWC1) within one day of learning of the injury or incident.

E. Follow up with the doctor to determine if there are job restrictions and explore the possibility of modified work.

F. Keep in touch with the employee during their recovery.

G. Keep in touch with your State Fund Adjuster.

Also see the form and additional special instructions by clicking on the above download link.

Need Adobe Acrobat Reader? Click on the image below to go to the Adobe site for the free download.