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DWC-1 First Report of Injury

NOTE: Adobe Acrobat Approval, Standard, or Professional version 5 or newer is required for submitting this form by email.

Use: Reporting claims by Employer to Carrier.

Filing Requirements:
Employer: Reporting all cases, except 1st aid cases to the carrier within 7 days of knowledge of the injury or accident. If the first aid claim becomes a medical only or lost time claim, then the employer shall report within 7 days of knowledge. The information on the form may be called in or faxed in to the carrier. The form should not be delayed because the employee signature is not available.

Statutory or Rule governing: 69L – 3.004, 3.0045.
Comments: the division assesses penalties if the form is not filed timely in all cases. Penalties are days 1-7 $100.00, days 8-14 $200.00, days 5-21 $300.00, days 22-28 $400.00; & 28 days & over are $500.00. Issues can be responded to in letter form to the division asking for ‘reconsideration of the penalty’ with a detailed explanation of why the NOI was not timely.

DWC-1a Wage Statement
Please follow the attached instructions when completing the DWC1a.

Mileage Reimbursement
This form is included for the worker’s convenience in requesting reimbursement for mileage incurred traveling to medical appointments in connection with the injury. Injured Worker’s can submit thoroughly completed forms to their examiner.

Employee Questionnaire
Initial Form to be completed by the injured worker.

Witness Statement
Form to be completed by a witness to the accident.

Medical Authorization
Authorization to obtain medical information.

Important Information for Florida Employers

Important Employee Information for Florida Workers

False or Fraudulent Claim Statement

Notice of Compliance (Broken Arm Poster)

Anti-Fraud Reward Program

Join the Battle Against Workers’ Compensation Fraud

Accident Investigation Report  

Michigan Office: toll free 800.262.4743 / Florida Office: toll free 877.925.9911 / email: info@mcim.com / terms of use