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INSURANCE

Workers’ Comp. Forms

Links to PDF format forms are provided below. To request printed forms, please contact Shannon Moore at 1.866.223.9587 or by e-mail: shannon@arsba.org.

Form 1 – First Report of Injury
Employer completes all questions and faxes (1.501.687.0225) to ASBA within 48 hours of being notified of the injury. If this is not possible, call Shannon Moore at ASBA (1.866.223.9587) for assistance.

Form N – Employee’s Notice of Injury
The injured employee must complete this form and give to the employer. The reverse side of the form describes the employee’s rights to receive medical treatment. The employer should retain a copy of Form N to be sent with Form 1 and provide a copy of both sides of the form to the employee.

Form S – Employer’s Supplemental Report of Injury
Complete when an employee is off from work for more than seven days. The form must be sent to ASBA each time an employee returns to work or starts missing time from work due to a work-related injury. A telephone call to report this information is also helpful and welcome.

Form P – Workers’ Compensation Notice
Post in a place where all employees may read it. The notice explains the procedures for filing a claim, includes contact numbers of the claims office and describes the rights of the employee and employer.