Report of Injury by Employee to Employer to be Filed with Worker's Compensation Agency of State

Workers' compensation laws are designed to ensure payment by employers for some part of the cost of injuries, or in some cases of occupational diseases, received by employees in the course of their work. Worker's compensation legislation requires the employer to furnish a reasonably safe place to work, suitable equipment, rules and instructions. State workers' compensation statutes vary by state. The Federal Employment Compensation Act covers non-military federal employees or those workers employed in some significant aspect of interstate commerce.

The compensation acts require that notice of the fact of injury be given to the employer, or to the compensation board or commission, or to the insurance carrier, or to all of them. This form is a generic example that may be referred to when preparing such a form for your particular state. It is for illustrative purposes only. Local laws should be consulted to determine any specific requirements for such a form in a particular jurisdiction.