Reporting on-the-Job Injuries

Employer Responsibilities

When an employer is notified on an on-the-job injury or illness, he/she must complete and submit a Workers Compensation - First Report of Injury or Illness (ACORD 4 Form / WCC Form 12-A) to the State Accident Fund immediately. This submission is critical. The employer, as well as the State Accident Fund, can be fined for failure to report claims to the Workers' Compensation Commission in a timely manner. Also, early intervention by a trained claims adjuster is essential to control claim costs and speed up an employee's return-to-work. Several studies have shown that delays in reporting injuries have an adverse impact on the cost of a claim and consequently on your premiums.

Submitting the WCC Form 12-A (First Report of Injury or Illness)

In order to report an injury please contact your medical management vendor (MMV). They will take all of the pertinent information, direct the injured worker to a doctor if needed and complete and send the 12-A to the State Accident Fund. We recommend you have the following items available when you begin calling the MMV:

  • the employee's personnel records.
  • the employee's payroll records.
  • any medical bills, reports, or statements containing information on the nature of the accident and/or the extent of the injury.

If you are affiliated with a state agency, and the injured employee has lost time from work due to the injury, explain to them and have them complete a Notice of Election Form containing the information shown in the example and it to SAF separately at the earliest possible time.

Mileage Reimbursement Form

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