Success!

The Employer's First Report of Injury has been submitted successfully.

The assigned claim number is:

You will receive a confirmation email that contains the injured worker's name and claim number. Provide the claim number and the name of insurance carrier to any medical provider rendering treatment to your injured employee.

If you need to make any changes to the completed form, please respond to the confirmation email or contact us using the information below.


Click here to view and print claim.

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Employer Instructions
OSHA 300 Log
Employee Instructions
Employee Instructions - Spanish
WCF Safety Courses
For technical assistance, please call 385.351.8919. For claims assistance, please contact Advantage at 800.962.5246 or at claims@advantagewc.com. For technical assistance please call 385.351.8919. For claims assistance please call 385.351.8000 or 800.446.2667.

Add Claim to OSHA Log









Insert title here
Wage Rate $ per Wage Unknown
Number of Days Worked per Week
Paid on Day of Injury?
Yes No
Did Salary Continue?
Yes No
(Date Last Worked and Date Disability Began
are only required if your employee will lose
time from work because of this injury.)
Location Where Accident Occurred
Yes No
Yes No Unknown
If yes, was it used?
Yes No
Initial Treatment
Yes No
Yes No
Yes No Unknown
Yes No Unknown
Details
Yes No
Details
Yes No
Details
Yes No Unknown
Details
OSHA Case/File #
Accident Cause Code
Injured employee language preference? English Spanish Other If other, please list:
Additional Information
Insert title here
Instructions

FRAUD - "Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison."