- This page, File an Employer's First Report of Injury, Illness or Death (Form 101) online, is offered by
- Department of Industrial Accidents
File an Employer's First Report of Injury, Illness or Death (Form 101) online
Contact for File an Employer's First Report of Injury, Illness or Death (Form 101) online
Francisco Pena, Claims Manager
The Details of File an Employer's First Report of Injury, Illness or Death (Form 101) online
What you need for File an Employer's First Report of Injury, Illness or Death (Form 101) online
You will need to know the following to complete the online Form 101:
- Name of your workers' compensation insurance company
- Name of injured worker and their personal information
- Date of Injury
- Where injury took place
- Type(s) of injury
- Body part(s) associated with the type(s) of injury
How to file File an Employer's First Report of Injury, Illness or Death (Form 101) online
- Login to the DIA's Content Management System (CMS) with your username/password
- Click "Expand" (red button) under the DIA Application Menu Tree
- Click on the "On Line Forms Submitted By Public" menu item
- You are then redirected to the online forms menu page
- Choose "Form 101 - First Report of Injury" and press "Continue"
- Locate the employer that you need to file the Form 101 for.
- You can either enter the Employer Identification Number (EIN) or search by employer name
- You can use a wild card for a partial search using the % sign.
- For example, to locate "ACME building and Construction, Inc." You can either enter "ACME" or "ACME Build%" or "%ACME%.
- Each search may retrieve a different result, if you can't find the correct employer you might need to refine your search.
7. Select a company from the result list that matches the employer by clicking on the company name.
- If you can't locate the employer after attempting multiple searches, you can press "New Company"
- You will be requested to enter the new employer information at a later step
- Please choose this option only after search attempts have failed to locate your requested employer
8. Choose the incident address.
- You may have more than one address to choose from
- If you can't locate an address where the incident occurred on the list, you can press "New Incident Address" and you will be requested to add the new address at a later step
9. Enter the employee information.
- Required fields are marked with an *.
- Press "Next" when you're done.
10. Select an insurer by clicking on the magnifying glass to the right of the insurer name field.
- A new pop up window will display, search for the appropriate insurer and select it
- Use the "Name" field to narrow the list
- The list will retrieve insurers that match the name you entered
- Click on "Select" next to the left of the required insurer
- After pressing select, the all the insurer name information will be populated in the insurer field
11. Fill in the other fields accordingly for other information you may have and press "Next".
12. Fill in the incident information. Required fields are marked with an *.
- Click on the icons to the right of the "Body Parts" and "Nature of Injury" sections and a pop up will display for you to make selections from
- If you pressed New Company/New Address/New Incident address previously, this is where you will have to fill these fields in
13. Press "Next" at the bottom of the page after you've completed it.
14. Please review the information entered and sign.
- If you need to correct any of the information, use the links on the left to return to the appropriate section for correction.
15. Enter your information (name, title and email address) and press "Submit" to conclude.
16. You should receive a DIA Transmittal number for your records.
- Keep this number for future reference or until you are assigned DIA Board Number
- You may print a copy for your records by selecting "Print" on the upper right-hand corner
- Follow the instructions for further submitting another form or returning to the DIA Application Tree
17. If you don't get a DIA Transmittal Number then the form has not been received by the DIA!