Submitting the First Report of Injury or Illness (WCC Form 12-A)

In order to report an injury, please contact your Medical Management Vendor. They will take all of the necessary information, direct the injured worker to a doctor, if needed, and complete and send the 12-A to the State Accident Fund. We recommend you have the following items available when you begin calling the Medical Management Vendor:

• the employee's personnel records
• the employee's payroll records
• any medical bills, reports, or statements containing information on the nature of the accident and/or the extent of the injury

If your are unsure who your Medical Management Vendor is, contact your claims adjuster.

If you are affiliated with a state agency and the injured employee has lost time from work due to the injury, have them complete a Notice of Election Form containing the information shown in the example and send it to the State Accident Fund separately at the earliest possible time.

Please see the two link attachments below for information regarding coordination of sick and annual leave with Workers' Compensation for 2019 and coordination of sick and annual leave with Workers' Compensation Payment.

2019-01-31- Sick and Annual leave with Workers' Compensation (PDF)

2019-01-31- Sick and Annual leave with Workers' Compensation payments (PDF)