Workers' Compensation Forms
For your claim to be accepted by Risk Services we must receive the following completed and signed packet.
Workers' Compensation Packet for Employees who work within Bernalillo County
Workers' Compensation Packet for Employees who work outside of Bernalillo County
There are 3 forms that must be completed:
The first page of the packet is the instruction page, explaining what information needs to be included to complete the 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. Make sure to complete the injury columns on the second page of this form. 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. The bottom of page 3 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.
Page 4 is the Notice of Accident of Occupational Disease Disablment form. The first signature line on the right must be signed by the injured employee and the second signature line must be signed by the employee's supervisor.
Page 5 is the Medical records release. This will ensure that the assigned adjuster is able to access the injured employee's health records for purposes of the claim.
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.
If there are additional questions please contact Risk Services directly here.
