Standard Form 3100 PDF Details

Are you in the process of filing a workers' compensation claim? If so, it's important that you know about standard form 3100, otherwise known as the "Employer's First Report of Injury or Illness." Whether you're an employer or employee dealing with a workplace-related injury or illness, getting familiar with this form is an essential step toward receiving assistance and benefits. In this blog post, we'll outline the purpose of Standard Form 3100 and discuss its importance when submitting your workers' comp case. It may seem intimidating at first, but having such essential knowledge can help to streamline your claim thoroughly and quickly.

QuestionAnswer
Form NameStandard Form 3100
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesva form 3036, NSN, 1987, Separations

Form Preview Example

Last Name

First Name

Middle Name

 

Date of Birth

Soc. Sec. No.

 

Agency

 

Payroll Office

 

Location

 

Payroll Office No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(RECORD EACH NAME CHANGE-STRIKE OUT PREVIOUS NAME)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Service History

 

 

 

 

 

 

 

 

 

Fiscal Record

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Effective Date

 

Action

 

 

Base Pay

 

Remarks

 

Year

Calendar Year

 

Accumulated

 

Remarks

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Salary

 

Salary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Deductions

 

Deductions

 

 

 

(1)

 

(2)

 

 

(3)

 

 

(4)

 

 

(5)

(6)

 

(7)

 

(8)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Register of Separations Number (SF 3103)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Office of Personnel Management

NSN 7540-01-247-0006

 

 

INDIVIDUAL RETIREMENT RECORD

 

 

 

 

Standard Form 3100

 

(Federal Employees' Retirement System)

 

 

 

 

5 CFR 841

 

 

3100-102

 

 

 

 

 

 

 

 

 

 

Revised January 1987

How to Edit Standard Form 3100 Online for Free

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Soc completion process shown (part 1)

2. The subsequent step would be to submit the next few blank fields: Register of Separations Number SF, US Office of Personnel Management, NSN, Individual Retirement Record, Federal Employees Retirement System, and Standard Form Revised January.

NSN, Individual Retirement Record, and Standard Form  Revised January of Soc

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