The Colorado WC 1 form is the official document used to report an employee's work-related injury or illness to the employer's insurance carrier. This form must be completed accurately and submitted within specific timeframes to ensure compliance with state regulations. If you need to fill out the Colorado WC 1 form, please click the button below.
The Colorado WC 1 form, officially known as the Employer’s First Report of Injury, serves as a crucial document in the workers' compensation process. This form must be completed whenever an employee sustains a work-related injury or illness, regardless of the severity. Key information required includes the employee's personal details, such as name, address, and Social Security number, as well as specifics about the injury, including the date it occurred, the nature of the injury, and the circumstances surrounding it. Employers must also indicate whether the employee was hospitalized, the average weekly wage at the time of injury, and whether any additional benefits like tips or health insurance were provided. The form must be submitted to the insurance carrier within ten days of the employer's knowledge of the injury. Accurate and complete information is essential to ensure compliance with Colorado's Workers' Compensation Act and OSHA requirements. In addition, the form includes sections for the employer's details, the insurance company's information, and a series of questions aimed at clarifying the incident, such as the part of the body affected and the activities leading up to the injury. The WC 1 form not only facilitates the claims process but also helps in tracking workplace safety and injury trends within the state.
See instructions on reverse side before
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
completing form.
EMPLOYER’S FIRST REPORT OF INJURY
Employee’s name (first, middle, last)
Social Security #
□ Male
Employee’s home phone #
OSHA
□ Female
(
)
Log #
Employee’s street address
City
State
Zip code
Birth date
/
Marital status
□ Separated
Date of hire
Occupation
Employment status
For
□ Married
□ Full time
□ Part time
Division
□ Single
□ Unknown
□ Other
use only
Employer’s name
Employer’s
Federal ID #
Employer’s phone #
SOI
Employer’s mailing address
POB
Average weekly wage at time
Check box if employee receives
Check if these benefits
are included in
AWW
NOI
of injury
□ Tips
□ Meals
$___________________
Coder
(see instructions on reverse side)
□ Room
□ Health insurance
Is the employer self-insured?
Were full wages paid for the DOI?
Are wages continued per C.R.S. 8-42-124? 1
□ Yes
□
No
Yes
Injury/Illness
Time employee
Injury time
Last day worked
Date employer
Date disability
Date returned to
date
began work
notified
began
work
____ ___ □ a.m.
____ ___□ a.m.
(See instructions
□ p.m.
on reverse side)
□ unknown
Did injury cause
If so,
Name, relationship, and address of closest dependent if injury caused
Injury
occurred because of
death?
□ No
date of death
death
Intoxication
□ Safety violation
□ Not applicable
Tell us the part of body that was affected
Tell us the nature of the injury/illness2
What was the employee doing just before the accident occurred?3
Tell us how the injury occurred4
What object or substance directly harmed the employee? 5
Did injury occur
Injury site address/ 9-digit zip code
Initial treatment (check one)
Was the employee hospitalized
on premises?
overnight as an in-patient?
□ None
□ Emergency room
□ Minor on-site
□ Hospital >24 hrs
□ Clinic/hospital
Names of witnesses
Name of employer representative notified
Name and address of treating doctor or other health care professional
Name and address of facility where treated
Completed by (name)
Title
Phone #
Date completed
The following is to be completed by the insurer prior to filing with the Division of Workers’ Compensation.
Name of insurance company
Address
Name of third party administrator (if applicable)
Adjuster name
Adjuster phone #
Policy #
Carrier claim #
Date insurer received first report
Block #
Adj. Code
WC 1 Rev 05/25
Page 1 of 2
INSTRUCTIONS
This form contains all items requested on OSHA Form No. 301,
“Injuries & Illnesses Incident Report”
General
•All injuries no matter how trivial must be reported to your insurance company.
•All injuries or occupational diseases which result in lost time from work in excess of three shifts or calendar days, or in permanent physical impairment, must be reported to your insurance carrier on this form within ten days after notice or knowledge of the injury or disease. Fatalities must be reported to your insurance carrier immediately.
•Forms should be typed or printed legibly.
•All questions must be answered completely to meet requirements of the Colorado Workers’ Compensation Act and to conform to the OSHA requirements for Form No. 301.
•The employer has the right in the first instance, to select the physician who attends the injured employee.
Calculation of Average Weekly Wage
•Determine the weekly wage rate.
•Add the average weekly amount of any overtime wages, tips or commissions.
•Add the average weekly value of any board, rent, housing, or lodging provided by the employer if the employer will not be paying such benefit during the period of disability.
•If the employee is covered by group health insurance and the employer does not continue the employee’s health insurance coverage during the period of disability, add the employee’s cost of conversion to a similar or lesser insurance plan and include this cost in the average weekly wage computation.
•Compute the total from the above categories and insert in the Average weekly wage at time of injury field.
Injury Date Information
In the case of an occupational disease, use the date of the last injurious exposure.
Notes
Are Wages continued per C.R.S. 8-42-124?1
(Subject to application with and approval of the Director of the Colorado Division of Workers’ Compensation)
1Any employer who is subject to the provisions of articles 40 to 47 of this title and who, by separate agreement, working agreement, contract of hire, or any other procedure, continues to pay a sum in excess of the temporary total disability benefits prescribed by articles 40 to 47 of this title to any employee temporarily disabled as a result of any injury arising out of and in the course of such employee's employment and has not charged the employee with any earned vacation leave, sick leave, or other similar benefits shall be reimbursed if insured by an insurance carrier or shall take credit if self-insured to the extent of all moneys that such employee may be eligible to receive as compensation or benefits for temporary partial or temporary total disability under the provisions of said articles, subject to the approval of the director.
Injury Description (Tell us the part of body that was affected. Tell us the nature of the injury/illness 2; What was the employee doing just before the accident occurred? 3; What happened? 4; What object or substance directly harmed the employee?5)
2Be more specific than “”hurt”, “pain”, or “sore.” Examples: “strained back”; “chemical burn, hand”; “carpal tunnel syndrome.”
3Describe the activity, as well as the tools, equipment or material the employee was using. Be specific. Examples: “climbing a ladder while carrying roofing materials”; “spraying chlorine from hand sprayer”; or “daily computer key-entry.”
4Tell us how the injury occurred. Examples: “When ladder slipped on wet floor, worker fell 20 feet”; “Worker was sprayed with chlorine when gasket broke during replacement”; “Worker developed soreness in wrist over time.”
5Examples: “concrete floor”; “chlorine”; “radial arm saw.” If this question does not apply to the incident, leave it blank
Notices
You are hereby notified that if a child support obligation is owed, compensation benefits may be attached and payment of the child support obligation may be withheld and forwarded to the obligee pursuant to sections 8-42-124 and 26-13-122, C.R.S. YOU ARE FURTHER NOTIFIED that you must provide written notice of any award for social security, pension, disability or other source of income that might reduce your compensation benefits. This notice must be sent to the insurance carrier or self-insured employer within 20 days after learning of the payment or award. Failure to report may result in suspension of your benefits pursuant to section 8-42-113.5, C.R.S.
C.R.S. Section 10-1-128 states: “It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purposes of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.”
Page 2 of 2
Completing the Colorado WC 1 form is a critical step in reporting an employee's work-related injury. This form collects essential information about the incident, the injured employee, and the employer. After filling out the form, it must be submitted to the appropriate insurance carrier within the specified timeframe.
The Colorado WC 1 form, also known as the Employer’s First Report of Injury, is a document that employers must complete when an employee is injured at work. It collects essential information about the employee, the injury, and the circumstances surrounding the incident. This form must be submitted to the insurance carrier within a specific timeframe to ensure compliance with Colorado workers' compensation laws.
The form should be submitted within ten days after the employer becomes aware of the injury or illness. If the injury results in a fatality, it must be reported immediately. All injuries, regardless of their severity, should be reported to the insurance company, especially if they lead to lost time from work exceeding three shifts or calendar days.
The form requires detailed information, including:
Completing the form accurately is crucial to meet the requirements of the Colorado Workers’ Compensation Act and OSHA regulations.
If the form is not submitted within the required timeframe, the employer may face penalties. Delays can lead to complications in processing the claim, which may affect the employee's access to benefits. It is essential to ensure that the form is completed and sent promptly to avoid any disruptions in benefits for the injured employee.
Omitting essential information such as the employee's Social Security number or date of hire can lead to delays in processing the claim.
Failing to provide a complete description of the injury or illness may result in insufficient details for the insurance company to assess the claim accurately.
Not specifying the nature of the injury can cause confusion. It is important to use clear terms rather than vague descriptions like "hurt" or "pain."
Incorrectly calculating the average weekly wage can lead to underpayment or overpayment of benefits. Ensure all relevant factors are considered.
Neglecting to check the self-insured status of the employer can lead to miscommunication about who is responsible for the claim.
Not answering all questions completely can result in the form being returned for additional information, delaying the claim process.
Failing to notify the employer or insurance company of any changes in the employee's condition can affect the outcome of the claim.
The Colorado WC 1 form, known as the Employer’s First Report of Injury, is a critical document for reporting workplace injuries. Alongside this form, there are several other documents that are commonly utilized in the workers' compensation process. Each of these documents plays a unique role in ensuring that the injured employee receives the necessary benefits and that the employer complies with state regulations.
Understanding these additional forms and documents can help both employers and employees navigate the complexities of workers' compensation claims in Colorado. Proper documentation is crucial for ensuring that injured workers receive the benefits they deserve while also protecting the interests of employers.
The OSHA Form No. 301, known as the "Injuries & Illnesses Incident Report," is similar to the Colorado WC 1 form in that both documents are designed to report workplace injuries and illnesses. The OSHA form requires detailed information about the incident, including the nature of the injury, the circumstances surrounding it, and any witnesses present. Like the WC 1 form, it aims to ensure that all injuries, regardless of severity, are documented and reported to the appropriate authorities. This helps maintain workplace safety and compliance with federal regulations.
The First Report of Injury (FROI) form is another document that resembles the Colorado WC 1 form. The FROI is used across various states to report workplace injuries to the relevant workers' compensation board. Similar to the WC 1, it collects essential information such as employee details, injury specifics, and employer information. Both forms serve the same purpose of initiating the claims process and ensuring that the injured employee receives the necessary benefits and support.
The Employer's Report of Injury form is also akin to the Colorado WC 1 form. This document is typically filled out by the employer when an employee sustains an injury at work. It includes information about the employee, the nature of the injury, and the circumstances of the incident. Like the WC 1, it is crucial for documenting the event and facilitating the workers' compensation process, ensuring that both the employer and employee fulfill their obligations under the law.
The Claim for Compensation form is another document that parallels the Colorado WC 1 form. This form is used by employees to formally request workers' compensation benefits after an injury. It requires similar information regarding the injury and the employee's work status. Both the Claim for Compensation and the WC 1 form are essential in establishing the basis for compensation and ensuring that the injured worker receives the benefits they are entitled to.
Lastly, the Worker's Compensation Claim Form, often utilized in various states, shares similarities with the Colorado WC 1 form. This document is submitted by employees to initiate a claim for benefits after a workplace injury. It gathers information on the employee's details, the nature of the injury, and the circumstances under which it occurred. Both forms aim to streamline the claims process and ensure that injured workers receive timely assistance and compensation for their injuries.
Filling out the Colorado WC 1 form correctly is crucial for ensuring that workers' compensation claims are processed smoothly. Here’s a guide on what you should and shouldn’t do when completing this important document.
By following these guidelines, you can help ensure that the claims process is efficient and that employees receive the benefits they deserve without unnecessary delays.
Understanding the Colorado WC 1 form is essential for both employers and employees involved in workplace injuries. However, there are several misconceptions that can lead to confusion. Here are five common misconceptions about this form, along with clarifications.
This is not true. All injuries, regardless of severity, must be reported to the insurance company. Even minor injuries require documentation to ensure proper tracking and compliance with regulations.
Calculating the AWW can be complex. It involves not just the base salary but also tips, overtime, and any benefits like housing or health insurance that may be provided. Employers must carefully consider all these elements to ensure accuracy.
While employers do have the right to select a physician initially, employees also have the right to seek medical treatment from their own choice of healthcare provider. This balance is crucial for ensuring that the employee receives appropriate care.
Timeliness is critical. The form must be submitted within ten days of the employer's knowledge of the injury. Failing to meet this deadline can result in complications regarding claims and benefits.
This form is significant for multiple parties, including insurance carriers and state agencies. It serves as a formal record that can impact the employee’s benefits and the employer's insurance premiums, making it vital for all involved to understand its importance.
When filling out the Colorado WC 1 form, it is crucial to ensure accuracy and completeness. Here are key takeaways to keep in mind:
Each step in completing the WC 1 form is vital to ensure compliance and proper processing of claims. Act promptly and accurately to avoid complications.