Free THE STATE OF NEW HAMPHSIRE - New Hampshire

This form must be printed and sent to the NH Department of Labor.
THE STATE OF NEW HAMPHSIRE DEPARTMENT OF LABOR SPAULDING BUILDING 95 PLEASANT STREET CONCORD, NEW HAMPSHIRE NOTICE OF ACCIDENTAL INJURY OR OCCUPATIONAL DISEASE 8aWCA
(Please print or type) To_____________________________________________________________________ Phone #______________________ (Name of Employer) ____________________________________________________________________________________________________ (Business Name and Address) IN ACCORDANCE WITH RSA 281-A:20, This is to notify you that an injury occurred. ______________________________________________________________________ SS #__________________________ (Name of Injured Employee) _____________________________________________________________Daytime Phone #_________________________ (Address of Injured Employee) ____________________________________________________________________________________________________ (Date of Accident or First Treatment) ____________________________________________________________________________________________________ (Place Accident Happened) Describe your injury or disease, and how it happened. Identify the body part(s) affected._____________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ I have been unable to work since my injury. __________ Yes __________ No

I have incurred the following medical bills. ______________________________ ___________________ ______________ Name of Doctor Dates of Service Amount

______________________________ ___________________ ______________ Name of Hospital Dates of Service Amount
______________________________ ___________________ ______________ Other Dates of Service Amount

__________________________________________________ (Employer's Signature) __________________________________________________ (Date)

_____________________________________________ (Employee's Signature) _____________________________________________ (Date)

This form can be returned to DOL with or without employer's signature.

NOTICE TO EMPLOYER
YOU MUST FILE AN EMPLOYER'S FIRST REPORT, Form No. 8WC, WITH THE LABOR COMMISSIONER AND THE NEAREST CLAIMS OFFICE OF YOUR INSURANCE CARRIER, AS SOON AS POSSIBLE AFTER ACQUIRING KNOWLEDGE OF THE OCCURRENCE OF AN OCCUPATIONAL INJURY OR DISEASE TO ONE OF YOUR EMPLOYEES OR UPON PRESENTATION OF THIS NOTICE BY HIM, BUT NO LATER THAN FIVE DAYS THEREAFTER. FAILURE TO COMPLY CARRIES AN AUTOMATIC CIVIL PENALTY OF UP TO $2500. (RSA 281-A:53) Form No. 8aWCA (Rev. 08/01) Employer's Copy ­ White Employee's Copy - Pink