You may no longer submit this form to the Office of Workers’ Compensation. Please complete the form and send to your insurer. (RS: )
Instructions For Completing The Employer Report Of Injury/Illness (LWC-WC-1007)
This Form Is Semi-Interactive And May Be Filled Out Online
This form has been formatted so that it can be completed online. Please complete the necessary information, print the completed form, then mail or fax the completed form as instructed. If you choose, you may print the blank form and submit in either typewritten form or in black ink.
Items with an asterisk are required and must be completed or your form will be returned. This form is due within 10 days of your knowledge of an incident which results in death or time lost from work in excess of 7 days. It is also due when you receive notice of a disputed claim (LWC-WC-1008) or when you have negotiated a lump sum settlement (LWC-WC-1011). It may also be requested at other times by the OWCA. It is the employer’s responsibility to complete this form and a copy must be provided to the employee. Failure to submit this form when required may result in a fine of up to $500.00 being assessed against the employer. The employer’s insurance carrier might also require this form. It is also presently accepted by OSHA in lieu of their form OSHA 101.