This form is filed by insurance carriers within 14 calendar days of the insurer's receipt of a First Report of Injury/Death form (Form 101), or an initial written claim for weekly benefits on an Employee's Claim Form (Form 110).

This form should be sent to the Department of Industrial Accidents at the address shown on the front of the form. Copies of this form must also be provided to the Employer, and by Certified Mail to the Employee.

Print Form 104  pdf format of Form 104

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