Employer Instructions For Completing The Les Form Dwc-1 printable pdf download

Employer Instructions For Completing The Les Form Dwc-1

Employer Instructions for Completing the LES Form

DWC-1

(First Report of Injury or Illness)

The LES Form DWC-1, or First Report of Injury or Illness, is the form used to

report workers’ compensation accidents or work-related illnesses to your

insurance carrier or designated claims office. Delays and errors may increase

costs related to processing the claim. Your prompt involvement from the

beginning is very important. Regular contact with the injured employee shows

your concern with his/her health and that you value his/her return to work. Your

commitment can assist in achieving the intent of the workers’ compensation

system of returning the injured employee to work, at a reasonable cost to you.

Your insurance carrier may allow different methods for reporting the accident

information to them; either by sending the LES Form DWC-1 itself, or by

submitting the information electronically. If sending the form to your insurance

carrier, be sure that you use the current revised LES Form DWC-1 (revised

11/’94). To avoid a fine of up to $500 for late reporting, the top two sections

(“Employee” and “Employer” sections) of this form must be completed in full and

reported to your insurance carrier within 7 days from your knowledge of the

injury or disease, unless it is a first aid case. A first aid case is a work injury

or illness which is treated at the workplace, does not require medical treatment

for which charges are incurred, and does not cause the employee to miss work

for more than one shift. If you are in doubt whether the workplace injury is a first

aid case, still file the LES Form DWC-1 with your insurance carrier. A copy of

the LES Form DWC-1 goes to the employee, two copies go to your insurance

carrier (Division and Carrier copies) and you keep one copy for your files, which

should be kept for not less than 2 years, 6 months.

Do not send a copy of the LES Form DWC-1 to the Division. Your insurance

carrier will complete its portion of the LES Form DWC-1 and send it to the

Division.

Remember: An employer must report all death cases to the Division of

Safety by telephone (850) 488-3044, telegram (address: 2002 Old St.

Augustine Road, Building E, Tallahassee, Florida 32301), or fax to (850)

922-4538 within 24 hours of knowledge of an employee’s death due to a

workplace accident or illness.

Employer Instructions For Completing The Les Form Dwc-1