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The law requires the DWC Form be completed whenever an injury beyond first aid occurs. Fill in the information below to create the DWC Form. Once completed, you must provide the DWC Form to the employee to be completed. Require the employee to return the completed form back you. Both sections must contain signatures from the employee and employer.

Full Name Of Injured Employee*

Employer Name*

Address, City, St. Zip*

Date Of Injury Reported By Employee

Date Employer First Knew Of Injury*

Date Claim Form Provided To Employee*

Insurance Policy Number

Title of Employer Representative*

Phone Number of Representative*

Workers Comp

Policy: Effective Date - Expiration Date:

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Was Injury Caused by Defective Equipment?

Yes

Provide dates and hours employee was not paid due to their injury.*

If injured employee is not able to work, will you continue paying their wages until they return to work?

Yes

Can you offer modified duty?

Yes

If mod duty is available, describe the modified duty.

Supervisor / Manager, please describe the injury: How, Who, What, Where, When, Why. Describe the activity the employee was performing.

Witness Statement: As a witness, please describe the injury: Who, What, Where, When, Why.

What changes to your safety program will you implement to prevent similar injuries from occurring, and when do you expect completion of this implementation?

Comments: Any suspicions, concerns, and additional information that can promote getting the worker back to work.

Your Risk Manager will contact you if further questions are needed.

E-Signature:

Benefits of Going Digital:

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