Claims Worker’s Report of Injury Form

An injured worker must file a workers’ compensation claim in writing with the Commission within one year after the injury occurred or when the injury becomes manifest which means that the injured worker knows or in the exercise of reasonable diligence should know that he or she has sustained a compensable work related injury.

An injured worker can make a claim for workers’ compensation benefits by filling out and signing a Worker's and Physician's Report of Injury at the doctor’s office or by completing this form as follows:

An injured worker or authorized representative may file a workers’ compensation claim for benefits by filing this form with the Commission. 

IMPORTANT:  This form must be completed in its entirety, including the name and address of the injured worker’s employer at the time of the alleged injury as well as the address or location of the accident.  Failure to do so may cause a delay in processing it.