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  2. Forms Repository
  3. WKC-12-E, Employer's First Report of Injury or Disease

Employer's First Report of Injury or Disease

Document Number: WKC-12-E

Description: This form is for the employer to report every work-related injury to its insurance company. If an employee is out more than 3 days due to a work-related injury, or there is PPD, a copy is to be sent to the Worker's Compensation Division by the employer's worker's compensation insurance carrier, not by the employer (unless the claim is a fatality). Except for fatalities, the information on this form must be sent electronically by the employer's worker's compensation carrier to the WC Division.

Comments: This form is an electronic Microsoft Word template that can be filled out on your computer (if you have Microsoft Word). We are also providing a PDF (WKC-12) which you can print and complete by hand.

Content Contact: Lynn Weinberger

Document Attachments:

WKC-12-E (English Electronic Version - Word/107 KB)

WKC-12 (English Print Version - pdf/200 KB)

WKC-12-E-S (Spanish Electronic Version - Word/112 KB)

WKC-12-S (Spanish Print Version - pdf/231 KB)

Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.

Contact Information

For questions about this form, or if you need this form in an alternate format, please see the Content Contact (listed to the left)

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