Policyholders

Report a claim

When an injury occurs, the claim needs to be reported immediately, even if you do not have all information.

BY WEBSITE

Complete a First Report of Injury Form, then upload:

Secure upload






BY EMAIL

Complete a First Report of Injury Form.
Return to:

BY FAX

Complete a First Report of Injury Form.
Return to:

  • FAX: 512-708-9487

BY PHONE

Simply call 888.981.1702 and advise that you are reporting a claim.
When calling in a claim, please have the following information ready:

  1. Your company name and location
  2. Injured employee’s name, social security number, phone number, job title, and rate of pay
  3. An explanation of what caused the accident, the nature of the employee’s injury, and the specific medical provider from the medical network with whom the injured employee will be treated.
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Forms

Alabama

EMPLOYER

First Report of Injury or Illness
First Report of Injury or Illness Codes


Arkansas

EMPLOYER

First Report of Injury or Illness (FORM-1)
Wage Statement


Arizona

EMPLOYER

First Report of Injury or Illness


California

EMPLOYER

First Report of Injury or Illness


Colorado

EMPLOYER

First Report of Injury or Illness


Connecticut

EMPLOYER

First Report of Injury or Illness


Delaware

EMPLOYER

First Report of Injury or Illness


Florida

EMPLOYER

First Report of Injury or Illness (Interactive)
Wage Statement DWC1A
Brochure for Employers

EMPLOYEE

Brochure for Injured Workers (ENGLISH)
Brochure for Injured Workers (SPANISH)


Georgia

EMPLOYER

First Report of Injury or Illness (WC1)


Idaho

EMPLOYER

First Report of Injury or Illness


Illinois

EMPLOYER

First Report of Injury or Illness


Indiana

EMPLOYER

First Report of Injury or Illness


Iowa

EMPLOYER

First Report of Injury or Illness


Kansas

EMPLOYER

First Report of Injury or Illness


Kentucky

EMPLOYER

First Report of Injury or Illness


Louisiana

EMPLOYER

First Report of Injury or Illness


Maryland

EMPLOYER

First Report of Injury or Illness


Massachusetts

EMPLOYER

First Report of Injury or Illness


Michigan

EMPLOYER

First Report of Injury or Illness


Minnesota

EMPLOYER

First Report of Injury or Illness


Mississippi

EMPLOYER

First Report of Injury or Illness
First Report of Injury or Illness Instructions


Missouri

EMPLOYER

First Report of Injury or Illness


Montana

EMPLOYER

First Report of Injury or Illness


Nebraska

EMPLOYER

First Report of Injury or Illness


Nevada

EMPLOYER

First Report of Injury or Illness


New Jersey

EMPLOYER

First Report of Injury or Illness IA1


New Hampshire

EMPLOYER

First Report of Injury or Illness


New Mexico

EMPLOYER

First Report of Injury or Illness


North Carolina

EMPLOYER

NC Employer Report of Injury or Illness (FORM-19)

EMPLOYEE

NC Employee Report of Injury or Illness (FORM-18a)
NC Notice of Accident (FORM-18ee)


Oklahoma

EMPLOYER

First Report of Injury or Illness


Oregon

EMPLOYER

First Report of Injury or Illness


Pennsylvania

EMPLOYER

First Report of Injury or Illness
Statement of Wages (LIBC-494a)


Rhode Island

EMPLOYER

First Report of Injury or Illness


South Carolina

EMPLOYER

First Report of Injury or Illness (FORM-12A)


South Dakota

EMPLOYER

First Report of Injury or Illness


Tennessee

EMPLOYER

First Report of Injury or Illness (DWC FORM-C20)
Wage Statement (C41)


Texas

EMPLOYER

First Report of Injury or Illness (DWC FORM-001)
Employer’s Wage Statement (DWC FORM-003)
Supplemental Report of Injury (DWC FORM-6)
Compensation Procedures (Chapter 120)

EMPLOYEE

Employee’s Claim for Compensation (DWC FORM-041)
Employee’s Claim for Compensation - Spanish (DWC FORM-041)


Utah

EMPLOYER

First Report of Injury or Illness


Vermont

EMPLOYER

First Report of Injury or Illness


Virginia

EMPLOYER

First Report of Injury or Illness


West Virginia

EMPLOYER

First Report of Injury or Illness


Wisconsin

EMPLOYER

First Report of Injury or Illness

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