Workers' Compensation Forms
Employer's First Report of Occupational Injury or Disease (Form 8WC) (fillable)
Notice of Accidental Injury or Occupational Disease (Form 8aWCA)
Employer's Supplemental Report of Injury (Form 13WCA) (fillable)
Wage Schedule (Form 76WCA) (fillable)
The forms listed above must
be sent to the NHADA Workers' Compensation Trust, preferably faxed to 224-8126. The Supplemental Report of Injury, 13WCA, is the only form that must be sent to the NH Dept. of Labor as well as the NHADA Workers' Compensation Trust.
NHADA Workers' Compensation Trust
P.O. Box 2337
Concord, NH 03302-2337
Fax: (603) 224-8126
State of New Hampshire
Department of Labor
P.O. Box 2077
Concord, NH 03302-2077
Fax: (603) 271-6149
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Accurate and prompt filing of required forms is the first step in successfully managing workers' compensation claims. The following is a description of what, when, where, and why to file the form required by the NH Department of Labor.
The Notice of Accidental Injury or Occupational Disease (8aWCA): an optional form utilized to give the
injured worker the opportunity to describe, in his or her own words, how the injury occurred. This form is to be completed by the injured employee and used by the employer to complete the Employer's First Report of Injury or Occupational Disease (8WC). The Notice of Accidental Injury or Occupational Disease (8aWCA) is the only form that the injured employee should complete. If the members use this form, please forward it to NHADA with the completed Employer's First Report of Injury.
The Employer's First Report of Injury or Occupational Disease (8WC) is the foundation of the workers' compensation process. This form must be fully and legibly completed by the employer within five calendar days of their knowledge of an employee's injury in the workplace. Late reporting of the claim carries with it up to a $2,500 fine. The Employer's First Report of Injury or Occupational Disease should never be given to the injured employee to complete. National studies have found that the longer it takes to report a claim, the more expensive the claim will be.
Please remember to fill in all of the questions on the form. Every piece of information contained on the form is necessary for the appropriate handling of the claim. The only exception is the SIC code which is no longer used by the Department of Labor. The employee's signature should be obtained when the employee is available. Do not delay the filing of the claim waiting for the employee to sign the form. The NHADA WCT claims department electronically uploads the information contained on the Employer's First Report of Injury every day. Therefore, it is no longer necessary for NHADA WCT members to send the Employers First Report of Injury or Occupational Disease (8WC) to the NH Department of Labor.
The Supplemental Report of Injury (13WCA) is the form utilized to notify the claims department of a change in disability status. It should be used in the following situations:
When the employee is disabled for four or more days;
When the employee returns to work after a period of work-related disability;
When the employee goes out of work after a period of working;
When the Employer's First Report of Injury is not clear relative to the employee's disability status; and
When the employee's hours or rate of pay changes when the employee is working in a temporary alternate duty status.
It is not necessary to file a Supplemental Report of Injury weekly when an employee is totally disabled from
work. It is important to notify us when an otherwise non-disabled employee becomes disabled and when a disabled employee returns to work.
The Supplemental Report of Injury is not uploaded electronically, so a copy must be filed with the NH Department of Labor.
The Wage Schedule (76WCA) must be completed if the injured employee is totally disabled 14 days or more or at the employee's request. The Wage Schedule must be completed based on the 26 weeks prior to the date of injury regardless of when the disability begins. The injured employee has the right to request that a 52-week Wage Schedule be completed. The Wage Schedule should not be submitted to the NH Department of Labor because the claims department will submit it with the Memo of Payment to the NH Department of Labor.
Updated June 12, 2018