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Date of This Report
District of Columbia Government
Office of Worker’s Compensation
Employee Social Security No.
P.O. Box 56098
Washington, DC 20011
(202) 671-1000 Employer Identification No.
Warning: It is a crime to provide false or misleading
information to an insurer for the purpose of defrauding Insurer No.
the insurer or any other person. Penalties include
imprisonment and/or fines. In addition, an insurer may
deny insurance benefits if false information materially
related to a claim was provided by the applicant.
EMPLOYER’S
FIRST
REPORT
OF
INJURY
OR
OCCUPATIONAL
DISEASE
Employee Name and Address: Employer Name and Address:
Insurer Name and Address:
IMPORTANT: Every employer shall file this report as soon as possible after knowledge of an occupational injury or disease to one of
his/her’s employees, but no later than ten days thereafter. Failure to file this form shall be subject to civil penalty not to exceed
$1,000.
Date and time of Injury _________________________________________am/pm? Day of the week?________________________________
Normal starting time ____________am/pm? If employee back to work, give date and time ___________________________________am/pm?
At what wage? ___________________________ If fatal, give date of death __________________________________(file supplement report)
Date of disability began? _________________________________ am/pm? Was the injured pai indfull for this day? ____________________
Was the injured given Form No. 7 DCWC? ____________________ Foreman___________________________________________________
When did you or the foreman first learn of the injury? _______________________________________________________________________
Male ________ Female _______ DOB __________ Employee’s Telephone No. _________________________________________________
Occupation when injured? _______________________________ Was this his/her regular occupation?_______________________________
(Department or branch regularly employed) ______________________________________________________________________________
Was the injured hired in DC? ________________ How long employed by you? __________________________________________________
Piece or time worker? ________________________________ Hourly wage? _____________ Hours worked/day _______________________
Daily wages _________________ Days worked per week _______________________________ Average weekly earnings______________
If board and lodging were furnished or gratuities reported in addition to wages, give estimated value per day, week or month:______________
Employer’s principal business function in DC _____________________________________________________________________________
Employer’s Telephone No. ______________________________________ Insurance Policy No. ____________________________________
Location of plant or place where accident occurred: ________________________________________________________________________
On employer’s premises? _______________________________
Describe fully the events which resulted in injury or disease, what the employee was doing when injured and type of injury including parts of the
body affected: _________________________________________________________________________________________________
Name of Witnesses _________________________________________________________________________________________________
Nature and location of injury (Describe fully): _____________________________________________________________________________
Attending Physician and Address (If Hospital Involved – Indicate):
________________________________________________________
Name (Please Print or Type)
_______________________________________________ ________________________________________________________
Name of Person Completing Form Signature
________________________________________________________
Official Position
Form No. 8 DCWC 9-2491