Please be advised that as of January 1, 2014 the Department of Industrial Accidents (DIA) will no longer accept paper copies of the Form 101 - Employers First Report of Injury/Fatality. As of January 1, 2014 the DIA will require electronic submission of all First Reports of Injury (FRI). All entities required to submit FRIs will have the option of submitting forms via Electronic Data Interchange (EDI) for batch data submissions, secure file transfer for completed PDF forms (Form 101s filled out and transmitted individually) or by filing the FRI forms individually via the DIA website using an authorized online account.

Filing the Form 101 via the online accounts only requires Internet connection and a valid user account. Accounts are provided free of charge and may be obtained by requesting an online account. You will receive a login and password within a few days of your request as well as instructions on use of the account and all features.

The Form 101 should be filled out when an employee is injured, or alleges an injury, and is unable to earn full wages for five or more calendar days (Mondays through Sundays). It is the responsibility of the employer to report an alleged injury, whether or not the employer agrees with the employee's claim or not.

This form must be filed within seven (7) calendar days (not counting Sundays and legal holidays), from the fifth day of disability.

Once you have completed the electronic Form 101, you should print out a copy for your records  You should make three (3) additional copies:

  • One for the employee.
  • One for your insurance company.
  • One for your own records.

Directions on how to fill out the Form 101 - Employer' First Report of Injury in:

How to Fill Out and Submit the Electronic Form 101 - First Report of Injury/Fatality pdf format of How to Fill Out and Submit the Electronic Form 101
file size 2MB

English Form 101 Directions - English pdf format of Form 101 Directions - English

Arabic Form 101 Directions - Arabic pdf format of Form 101 Directions - Arabic

Cape Verdean Form 101 Directions - Cape Verdean pdf format of Form 101 Directions - Cape Verdean

Chinese Form 101 Directions - Chinese pdf format of Form 101 Directions - Chinese

Haitian Creole Form 101 Directions - Chinese pdf format of Form 101 Directions - Chinese

Khmer Form 101 Directions - Khmer pdf format of Form 101 Directions - Khmer

Portuguese  Form 101 Directions - Portuguese pdf format of Form 101 Directions - Portuguese

Spanish Form 101 Directions - Spanish pdf format of Form 101 Directions - Spanish

Vietnamese Form 101 Directions - Vietnamese pdf format of Form 101 Directions - Vietnamese