5 Forms for Workers Comp

For your claim to be accepted by Risk Services we must receive the following completed and signed forms.

There are 5 forms in total, as follows: 

  1. First Report of Accident - Instructions and E1-1 Form (Employees in Bernalillo County)
    1. First Report of Accident - Instructions and E1-1 Form (Branch Campus Employees or Employees Injured while Outside of Bernalillo County)
  2. Medical Records Release
  3. Notice of Accident
  4. Worker's Compensation Claim Explanation Form
  5. Worker's Compensation Benefits Explanation Form

The First Report of Accident form is the basic notice of the incident, This form lets Risk Services and the injured workers' direct supervisor know that an incident has occurred. This form should be completed regardless of whether the supervisor was a witness to the injury/accident or not.

The first page of the First Report of Accident form is the instruction page, explaining what information needs to be included to complete the form. The second and third pages are where the accident details are included. Please complete these pages to the best of your memory and ability and be as detailed as possible. If necessary, you may attach an additional sheet to better explain the incident.  

Make sure to complete the injury columns on page 2. Each column includes detailed fields to be circled to explain the incident. At the bottom of each column is a place to write in the corresponding code number so that the code is properly entered by Risk Services, please complete this step. The bottom of page 2 is to be completed and signed by your supervisor. If the direct supervisor is unavailable the next level manager or director must sign the form in their place.

The remaining 4 forms must also be completed and submitted to Risk Services as quickly as possible but no later than 15 days after the incident/injury.

If there are additional questions please contact Risk Services directly here.