The New Hampshire Employer's First Report of Occupational Injury or Disease Form is a document that employers are required to submit to the New Hampshire Department of Labor within seven days of an employee suffering an occupational injury or illness. The form includes information such as the date, time, and location of the incident, a description of the injury or illness, the name and contact information of the employee, and the name of the doctor who treated the employee. The form also requires employers to list the type of work the employee was doing at the time of the injury, the type of injury or illness the employee suffered, and the steps taken to prevent further injury or illness. The New Hampshire Employer's First Report of Occupational Injury or Disease Form is typically available in paper form, online, or in PDF format. There are two versions of this form: one for employers with fewer than 11 employees, and one for employers with 11 or more employees.
New Hampshire Employer's First Report of Occupational Injury or Disease Form
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How to fill out New Hampshire Employer's First Report Of Occupational Injury Or Disease Form?
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FAQ
The average cost of workers' compensation in New Hampshire is $35 per month. Your workers' comp premium is calculated based on a few factors, including: Payroll.
The employer is required to file an Employer's First Report of Injury or Illness DWC FORM-001 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.
New Hampshire Workers' Compensation & First Report of Injury Once you fill out the form, you can: Fax it to: 603-271-6149. Mail it to: Workers' Compensation Division, NH Department of Labor, 95 Pleasant St., Concord, NH 03301. Email it to: WorkersComp@dol.nh.gov.
Report the injury or illness to your employer If you don't report your injury within 30 days, you could lose your right to receive workers' compensation benefits.
Weekly Compensation Benefits Under NH law an injured worker is to be paid 60% of their pre-injury average weekly wage while they are out of work due to a work related injury. These benefit payments are issued by the insurance company on a weekly basis and are tax free.
Fill out an accident report (form 8aWCA) right away. You can get this form from the employer. Make sure to keep a copy for yourself. You have up to two years to report workplace injuries and illnesses, but it is best to report right away.
The injured worker has two (2) years from the date of injury to notify the employer of his injury in order to make a claim for benefits.
The Employer's Report of Occupational Injury or Illness (Form 5020). Every employer is required to file a complete report of every occupational injury or illness to each employee which results in lost time beyond the date of injury or illness or which requires medical treatment beyond first aid.