Form 101 – Employer’s First Report of Injury

Only Electronic Submissions Are Accepted by the DIA

It has come to our attention that some insureds may not have received the DIA notice advising that as of January 1, 2014 the Department of Industrial Accidents (DIA) will no longer accept paper copies of the Form 101 – Employers First Report of Injury/Fatality.

The instructions on the website at this link state:

As of January 1, 2014 the DIA will require electronic submission of all First Reports of Injury (FRI). All entities required to submit FRIs will have the option of submitting forms via Electronic Data Interchange (EDI) for batch data submissions, secure file transfer for completed PDF forms (Form 101s filled out and transmitted individually) or by filing the FRI forms individually via the DIA website using an authorized online account.

Filing the Form 101 via the online accounts only requires Internet connection and a valid user account. Accounts are provided free of charge and may be obtained by requesting an online account. (On the page, the underlined words is a link to the online account sign up.) You will receive a login and password within a few days of your request as well as instructions on use of the account and all features.

The Form 101 should be filled out when an employee is injured, or alleges an injury, and is unable to earn full wages for five or more calendar days (Mondays through Sundays). It is the responsibility of the employer to report an alleged injury, whether or not the employer agrees with the employee’s claim or not. (Note, all injuries should be reported to your insurance company/agency even when lost time is less than the five day Form 101 reporting requirement.)

This form must be filed within seven (7) calendar days (not counting Sundays and legal holidays), from the fifth day of disability.

Once you have completed the electronic Form 101, you should print out a copy for your records you should make three (3) additional copies:

  • One for the employee.
  • One for your insurance company/agency.
  • One for your own records.

Also included on that same web page are detailed instructions on How to Fill Out and Submit the Electronic Form 101 on line.

We hope you find this information helpful.

Very truly yours,
DeSanctis Insurance Agency, Inc.