Success!

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

The assigned WCF claim number is:

You will receive a confirmation email that contains the claimant's name, date submitted and WCF claim number. Employers are required by law to provide the injured worker with a copy of the claim and information on his/her rights and responsibilities.

WCF will forward a copy of the claim to the Utah Labor Commission.


Click here to view and print claim.
  1. Employer Instructions
  2. Employee Instructions
  3. Employee Instructions - Spanish
  4. OSHA 300 Log
  5. WCF Safety Courses
  6. File Another Claim

For technical assistance please call 385.351.8919. For claims assistance please call 385.351.8000 or 800.446.2667.


Add WCF 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 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
Employer and Employee 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."