Form L 1 1 PDF Details

The State of New Jersey mandates the use of the Employer's First Report of Accidental Injury or Occupational Illness form, known commonly as the L-1-1 form, to ensure that workplace accidents or illnesses are reported promptly and accurately. This form plays a critical role in the Workers' Compensation process, helping both employers and employees navigate the aftermath of workplace incidents effectively. Employers are required to fill out this form in cases where an injury or illness leads to the loss of time beyond the initial work shift, requires medical treatment beyond first aid, or in the instance of an occupational illness, regardless of time lost. It captures a range of details, including the insurance carrier information, the date and time of the incident, a thorough description of the incident, and the personal details of the affected employee. Employers must submit this report as soon as possible, and no later than the start of the second workday after the incident, to ensure rapid response and support for the injured or ill employee. Furthermore, in the event of serious or fatal injuries, it mandates immediate action. This form also opens the door for employees to understand their rights regarding potential unemployment insurance benefits while recovering from a work-related injury or illness. The comprehensive nature of the L-1-1 form underscores New Jersey's commitment to worker safety, health, and welfare, as well as facilitating a structured approach to workers' compensation claims.

QuestionAnswer
Form NameForm L 1 1
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesNewJersey state of new jersey employers first report of accidental injury or occupational illness form

Form Preview Example

STATE OF NEW JERSEY

EMPLOYER'S FIRST REPORT OF ACCIDENTAL INJURY OR OCCUPATIONAL ILLNESS

1. CARRIER NAME. ADDRESS

IA. POLICY NUMBER

1B. EFFECTIVE DATE

EXPIRATION DATE

 

 

 

 

 

2. DATE OF INJURY OR ILLNESS

TIME OF DAY

 

 

 

 

 

SEND REPORT

 

 

 

 

IMMEDIATELY

MAIL DUPLICATE

 

 

 

 

AFTER INJURY

(YELLOW) TO

 

 

DO NOT WAIT FOR

 

O.S.H.A. CASE NUMBER

DOCTOR'S REPORT

 

 

 

 

 

 

 

 

 

THIS FORM (IN QUADRUPLICATE) MUST BE COMPLETED IN THE FOLLOWING CASES ONLY:

(1)FOR EVERY ACCIDENTAL INJURY OF ILLNESS WHICH SHALL CAUSE A LOSS OF TIME FROM REGULAR DUTIES BEYOND THE WORKING DAY OR SHIFT INCLUDING SUNDAY OR ANY DAY ON WHICH EMPLOYEE WOULD USUALLY WORK, OR

(2)WHICH SHALL REQUIRE MEDICAL TREATMENT BEYOND ORDINARY FIRST AID. OR

(3)FOR THE OCCURRENCE OF AN OCCUPATIONAL ILLNESS WHETHER OR NOT TIME IS LOST.

COMPLETE THIS FORM IN ACCORDANCE WITH THE INSTRUCTIONS ON BACK OF THIS WHITE SHEET. MAIL IT PROMPTLY AS POSSIBLE. IN ALL CASES NO LATER THAN THE START OF THE SECOND (2nd) WORK DAY AFTER INJURY OCCURRED, IN CASE OF A FATAL OR SERIOUS INJURY (one that requires hospitalization) COMPLETE AND MAIL THIS IMMEDIATELY.

 

PLEASE PRINT OR TYPE

 

 

 

 

New Jersey Registration No.

 

 

 

 

 

 

SEE DETAILED INSTRUCTIONS ON REVERSE SIDE (White Sheet)

 

 

 

 

 

 

or

 

 

 

 

 

 

 

3. FIRM NAME

 

 

 

 

 

4.

Federal Employer

5. S.I.C. NO.

6. NO. OF EMPLOYEES

 

 

 

 

 

 

 

 

identification No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. TELEPHONE NO. (Area Code)

9. NATURE OF BUSINESS

 

 

7. MAILING ADDRESS (Please include City, Zip)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION, IF DIFFERENT FROM MAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. NAME: LAST NAME - FIRST NAME MIDDLE NAME

11. SOCIAL SECURITY NO.

12. Date of Birth

13. AGE

14. SEX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. HOME ADDRESS (Number and Street, City. Zip, County)

16. OCCUPATION (Regular Job Title)

Mo.

Day

 

Yr

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17. DEPARTMENT WHERE

 

 

 

 

 

 

 

 

 

 

EMPLOYED'

 

 

18. TELEPHONE NO. (Area Code)

19. WAGES

 

 

 

20. NO. of HRS. (Regular work day)

 

 

 

 

 

 

 

 

 

 

 

 

 

Weekly $

Hourly $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21. WHERE DID ACCIDENT OR EXPOSURE OCCUR? (Address, City, County)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22- WHAT WAS EMPLOYEE DOING WHEN INJURED? (Be Specific) (Please use separate sheet if necessary)

 

 

 

 

 

 

23.OBJECT OR SUBSTANCE, MACHINE OR TOOL THAT DIRECTLY INJURED EMPLOYEE

24.NATURE OF INJURY OR ILLNESS AND PART OF BODY AFFECTED (Formal Diagnosis Not Required)

 

25. 010 EMPLOYEE DIE?

26. WAS EMPLOYEE UNABLE TO WORK ON ANY

27. HAS EMPLOYEE RETURNED TO WORK?

 

 

 

 

 

DAY AFTER INJURY?

 

 

 

 

 

 

 

Yes. date

 

 

 

 

Yes, date last worked

 

Yes, date

 

 

 

 

No

 

 

 

No

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28. NAME OF TREATING DOCTOR. IF ANY

 

29. DOCTOR'S ADDRESS: (Number and Street. City. Zip)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

30. IF HOSPITALIZED. Name of Hospital

 

 

31. ADDRESS OF HOSPITAL (Number and Street. City. ZIP)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPLETED BY: (Print or Type)

 

TITLE:

 

 

IMPORTANT NOTICE OF SPECIAL FILING RIGHTS

 

 

 

 

 

 

 

 

 

 

FOR UNEMPLOYMENT INSURANCE BENEFITS

 

 

 

 

 

 

 

 

 

 

SIGNATURE:

 

DATE:

 

 

 

 

 

 

 

 

 

 

 

 

The New Jersey Unemployment Compensation Law provides

 

 

 

 

 

 

 

 

 

special filing rights for workers upon recovery from a work-related

 

 

 

 

 

 

 

 

 

 

NEW JERSEY DEPARTMENT OF LABOR

 

 

injury or illness.

 

 

 

 

 

 

 

 

 

 

 

 

 

DIVISION OF WORKERS' COMPENSATION

MAIL

Eligibility for unemployment insurance benefits may be based

 

 

 

 

 

 

 

 

 

 

 

upon wages earned prior to your disability.

 

 

 

 

CN 381

 

 

 

ORIGINAL

 

 

 

 

 

 

 

 

TRENTON, NEW JERSEY 08625-0381

(White) TO

NOTE. THESE BENEFITS ARE POTENTIAL UNEMPLOY-

 

 

 

 

 

 

 

 

 

 

 

 

 

MENT INSURANCE BENEFITS. YOU SHOULD CON-

 

 

 

 

 

 

 

 

 

 

TACT THE DIVISION OF PROGRAMS - UNEMPLOY-

 

BLUE COPY RETAINED BY EMPLOYEE.

 

 

 

MENT AND DISABILtTY INSURANCE FOR

 

PINK COPY FOR PERSONNEL RECORDS.

 

 

 

ADDITIONAL INFORMATION. DO NOT CONTACT

 

 

 

 

 

 

 

 

 

THE DIVISION OF WORKERS' COMPENSATION.

FILING OF THIS REPORT IS NOT AN ADMISSION OF LIABILITY

 

L & 1-1 (R-6-92)

INSTRUCTIONS

1 . CARRIER NAME, ADDRESS: Indicate the name and address of the firm's Workers' Compensation carrier. if self-insured, indicate *self- insured''.

1A. POLICY NUMBER: Indicate the firm's Workers' Compensation Insurance policy number.

1B. EFFECTIVE DATE: Indicate the date when the present policy started. EXPIRATION DATE: Indicate the date when the present policy expires.

2.DATE OF INJURY OR ILLNESS: Indicate the date when the injury occurred or in case of illness, when first detected. TIME OF DAY: Indicate the time of injury or illness (i.e. 9:30 a.m. or 7:00 p.m.)

O.S.H.A. CASE NUMBER: (Leave Blank)

3.FIRM NAME: Indicate the full name of individual, partnership, corporation or trade name of the employer.

4.NEW JERSEY REGISTRATION NUMBER OR FEDERAL EMPLOYER IDENTIFICATION NUMBER: Indicate either your company's New Jersey Registration Number or your company's Federal Employer Identification Number. This number can be obtained from your copy of Quarterly Report of Wages (Form U.C. 27B). The account number is on the fifth line of the address.

S. S.I.C. Number: Indicate the S.I.C. Number of your firm. This number can be obtained from your copy of Quarterly Report of Wages (Form U.C. 27B). The S.I.C. isthe four digit number in the lower right hand corner of the address under the account number.

6.NO. OF EMPLOYEES: The number of employees employed by the firm.

7.MAILING ADDRESS: The address of the employer.

8.TELEPHONE NO. (AREA CODE): The business telephone of the employer.

9.NATURE OF BUSINESS: Describe the kind of business of the employer, i.e. manufacture shoes, wholesale food, retail clothing, construction, transportation, communication, utilities, government, etc.

LOCATION, IF DIFFERENT FROM MAILING ADDRESS: If the location where the injury or illness occurred is different from the mailing address of the employer in question #3.

10.NAME: Indicate the full name of the employee as carried on payroll records.

11.SOCIAL SECURITY NO.: Indicate the Social Security number of the employee.

12. DATE OF BIRTH:

13. AGE:

14. SEX: (Self-explanatory)

15.HOME ADDRESS: The address of the employee.

16.OCCUPATION: The job classification of employee, i.e., carpenter, electrician, driver, lathe operator, salesperson, etc.

17.DEPARTMENT-WHERE EMPLOYED: indicate under which agency within the firm that the employee worked.

18.TELEPHONE NO.-, The home telephone of employee.

19.WAGES: if employee is paid weekly salary indicate gross weekly amount. If employee is paid hourly indicate hourly rate. (exclude overtime)

20.NO. OF HOURS: Indicate the total regular number of hours employee works per day. (exclude overtime)

21.WHERE DID ACCIDENT OR EXPOSURE OCCUR? If the location of accident or exposure is different from the address shown on line 7, give sufficient information to pinpoint location by giving address, city, county, route orjob location.

22.WHAT WAS EMPLOYEE DOING WHEN INJURED? Examples: walking down stairs, climbing ladder, operating table saw, changing wheel on grinder, sitting at desk, opening file drawer, etc.

23.OBJECT OR SUBSTANCE, MACHINE OR TOOL THAT DIRECTLY INJURED EMPLOYEE Examples: stairs and handrail, floor, saw blade, dust, vapors, chips, chisel, hammer, chain, acid (name), steam, fire, hot sluge, electric current, the item employee was lifting, pushing or pulling, etc.

24.NATURE OF INJURY OR ILLNESS AND PART OF BODY AFFECTED Examples: amputation of right index finger, fracture of ribs, burn of left hand, contusions of both legs, laceration of upper right arm, etc.

Examples of occupational disease: dermatitis of neck, silicosis, etc.

25.DID EMPLOYEE DIE? Was the injury or illness the cause of death?

26.WAS EMPLOYEE UNABLE TO WORK ON ANY DAY AFTER INJURY? (Self-explanatory).

27.HAS EMPLOYEE RETURNED TO WORK? (Self-explanatory).

28, 29, 30, 31 (Self-explanatory)

Form L 1 1 isn’t the one you’re looking for?

Related Documents