Employer's first report of injury or fatality

Filing instructions

1. When to file: File this form within 7 calendar days, not including Sundays and legal holidays, of receipt of notice of any injury alleged to have arisen out of and in the course of employment, which totally or partially incapacitates an employee for a period of 5 or more calendar days from earning wages. This form is not an admission of liability, but must be filed even though the employer may believe that the employee is not injured, or that the employee is not entitled to benefits under M.G.L. Chapter 152.

2. Where to file: This form should be mailed to the Department of Industrial Accidents at the address shown on the front of the form. Copies must also be provided to the employee and to the employer's Workers' Compensation insurer.

3. Penalties: Failure to report injuries on this form may result in a fine of $100.00 in accordance with M.G.L. Chapter 152, Section 6.

4. Employer's name & signature in boxes 37 & 39: This form must be filed by the employer or an authorized agent/representative of the employer.