After submission, you will have an option to download and print your WC1 form.
Every work injury to an employee causing absence for one day or more or which requires medical services other than first aid treatment
must be reported within 7 working days after the injury. Failure to report promptly is a misdemeanor punishable by not m ore than a
$5,000 fine. (Sec 386-95, H.R.S. NOTIFY THE DIVISION IMMEDIATELY IF INJURY RESULTS IN DEATH.) EVERY QUESTION
MUST BE ANSWERED FULLY TO AVOID FURTHER CORRESPONDENCE.
The law requires the employer
to furnish the injured employee
a copy of this report.
WC-1 EMPLOYER’S REPORT OF INDUSTRIAL INJURY
CASE NUMBER
IDENTIFICATION SECTION
N O T E :
D O N O T W R I T E I N S H A D E D B L O C K S
EMPLOYEE NAME – LAST
ADDRESS
FIRST
M.I.
SOC SEC NO
DATE OF BIRTH
MM
/
DD
/
YY
CITY
SEX
MALE
MARITAL STATUS
MARRIED
DATE RECEIVED
ADDITIONAL ADDRESS INFORMATION (C/O)
FEMALE
SINGLE
STATE
MM
/
DD
/
ZIP CODE
YY
PHONE
OCCUPATION
DATE HIRED
YRS EMP’D
DEPARTMENT
PAYROLL COMP
OCC. CODE
REGISTERED EMPLOYER
MM
/
DD
/
YY
CODE
|
CLASS CODE
DBA
ADDRESS
CITY
STATE
ZIP CODE
PHONE
NATURE OF BUSINESS
DATE INJURY/ILLNES REPORTED
DATE OF INJURY/ILLNESS
PREFAB
DOL NUMBER
DBA
MM
/
DD
/
YY
MM
/
DD
/
YY
WC -2
WC -5
DETAIL OF INJURY / ILLNESS
TIME OF INJURY/ILLNESS
TIME OF I/I CODE
PLACE OF I/I IF DIFFERENT FROM EMPLOYER’S MAILING ADDRESS
CITY
STATE
ON EMPLOYER’S
INDUSTRIAL CODE
PREMISES
_____AM
____PM
|
|
|
YES
NO
SOURCE OF INJURY
EVENT
HOW DID THIS ACCIDENT OCCUR? (Please describe fully the events that resulted in injury or occupational disease.
Tell what happened. Please use separate sheet if necessary)
TASK
ACTIVITY
ACCIDENT FACTOR
AOS
OBJECT OR SUBSTANCE THAT DIRECTLY INJURED EMPLOYEE (e.g. the machine employee struck against or struck him; the vapor or poison inhaled or swallowed;
the chemical that irritated his skin. In cases of strains, the thing he was lifting, pulling, etc.)
DESCRIBE IN DETAIL THE NATURE OF THE INJURY, ILLNESS
AND PART OF THE BODY AFFECTED
Y ES
NO
NATURE OF INJURY
PART OF BODY
DISFIGUREMENT
BURNS
TIME LOST INFORMATION
DATE DISABILITY BEGAN
AVG WKLY WAGE
WAS EMPLOYEE PAID IN FULL
IF EMPLOYEE DIED GIVE DATE
HOURLY WAGE
MONTHLY SALARY
HRS WKED / WK
WEIGHING
MM
/
DD
/
YY
WAS EMPLOYEE FURNISHED
MEALS OR LODGING?
YES
NO
|
IF EMPLOYEE IS BACK TO
WORK GIVE DATE
MM
/
DD
/ YY
FOR DAY OF INJURY/
ILLNESS?
YES
NO
MM /
DD
/
YY
|
|
GIVE NAME AND ADDRESS OF SURVIVORS ON BACK
|
FACTOR
TREATMENT
NAME OF PHYSICIAN
OBTAIN NAME OF TREATING PHYSICIAN FROM EMPLOYEE
ADDRESS
PHYSICIAN I.D. CODE
NAME OF MEDICAL FACILITY
ADDRESS
INPATIENT OVERNIGHT?
YES NO
EMERGENCY ROOM ONLY?
INSURANCE
CARRIER I.D.
NAME OF WC INSURANCE CARRIER
NAME OF ADJUSTING COMPANY
IF LIABILITY DENIED – WHY?
IS LIABILITY DENIED?
YES
NO
POLICY NO.
POLICY PERIOD
-
ADJUSTER NAME
CARRIER CASE NO.
ADJUSTER I.D.
MEDICAL DEDUCTIBLE
SIGNATURE
TITLE
DATE

After submission, you will have an option to download and print your WC1 form.
Upload in Progress. Please wait