THIS FORM IS NO LONGER AVAILABLE TO BE PRINTED, MAILED OR EMAILED, NOR WILL IT BE ACCEPTED BY THE DIA INA PAPER FORMAT. AS OF JANUARY 1, 2014 THE FORM 101 MUST BE FILED ELECTRONICALLY VIA AN ONLINE DIA ACCOUNT.
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 three (3) 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:
English Form 101 Directions - English
Arabic Form 101 Directions - Arabic
Cape Verdean Form 101 Directions - Cape Verdean
Chinese Form 101 Directions - Chinese
Haitian Creole Form 101 Directions - Chinese
Portuguese Form 101 Directions - Portuguese
Spanish Form 101 Directions - Spanish
Vietnamese Form 101 Directions - Vietnamese