Transcription of WC-1 EMPLOYER’S REPORT OF INDUSTRIAL INJURY ... - …
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WC-1 EMPLOYER’S REPORT OF INDUSTRIAL INJURY ... - …
Every work INJURY to an employee causing absence for one day or more or which requires medical services other than first aid treatmentmust be reported within 7 working days after the INJURY . Failure to REPORT promptly is a misdemeanor punishable by not more than a$5,000 fine. (Sec 386-95, NOTIFY THE DIVISION IMMEDIATELY IF INJURY RESULTS IN DEATH.) EVERY QUESTIONMUST BE ANSWERED FULLY TO AVOID FURTHER law requires the employerto furnish the injured employeea copy of this EMPLOYER S REPORT OF INDUSTRIAL INJURYCASE NUMBERIDENTIFICATION SECTIONN 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 SEMPLOYEE NAME SEC NODATE OF BIRTHMM / DD /YYSEXMALEFEMALEMARITAL STATUS MARRIEDSINGLEDATE RECEIVEDMM /DD / YYADDRESSADDITIONAL ADDRESS INFORMATION (C/O)CITYSTATEZIP CODEPHONEOCCUPATIONDATE HIREDMM/DD/YYYRS EMP DCODE|DEPARTMENTPAYROLL COMPCLASS CODEOCC.
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 more than a $5,000 fine. (Sec 386-95, H.R.S. NOTIFY THE DIVISION IMMEDIATELY IF INJURY ...
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