This form 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.
The form with the original signature should be sent to the DIA. You should make three (3) additional copies:
- One for the employee.
- One for your insurance company.
- One for your own records.
Download the Form 101 - Employer' First Report of Injury 101.pdf
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