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.
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.