What you'll need to fill out
the First Report
Make the job easier by pulling together the information about the incident before you start filling out the First Report of Injury form.
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Letters that SFM sends injured employees are sometimes returned because the addresses are outdated. Employee addresses are taken directly from the First Report submitted by the employer. An outdated address can mean delays in getting important information or the initial benefit check to the injured employee.
When you fill out the First Report, be sure to verify that the employee address you're giving SFM is current--especially if you're pulling information from an employment application. You may need to verify the address by comparing with other human resources files or by calling the employee. |
Most of it may be in the
employee's personnel file.
For the First Report, here's what you'll need:
- Employee's Social Security number.
- Employee's full name.
- Employee's date of birth.
- Employee's current address.
- Accurate wage information. This will be used
to reimburse the injured employee for lost wages
due to doctor appointments or disability.
What's the employee's rate per hour?
How many hours per day and days per week
does the employee work?
Is the employee full time, part time, seasonal
or a volunteer?
Is the employee an apprentice?
Does the employee have a second job?
- Date the employer was notified or became
aware of the injury. "Employer" is you or
any manager or supervisor in the company.
This date starts the clock ticking toward state deadlines for paying or denying the claim.
- Minnesota: Date of first day of lost time, and date employer was notified of lost time.
- Wisconsin: Date of last day worked, even if a partial day.
- Date employee returned to work.
- Did you pay the employee for lost time on the day of injury?
- Details about the accident:
How did the injury occur?
What was the employee doing before the
incident?
What was the injury or illness? Include specific parts of the body. For example, broken left leg.
What tools, equipment, machines, objects or substances were involved? If the injury was due to faulty equipment, SFM may seek reimbursement from a third party, such as the manufacturer.
- Treating physician's name, address and phone number along with the
hospital or clinic name, if the employee sought treatment.
If you're puzzled by what a certain section of the First Report is asking, see your SFM Employer Kit for clarification, or call an SFM claims
representative at (952) 838-4200 or
(800) 937-1181, option 0 (zero).
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