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Report a claim for NEW HAMPSHIRE

EMPLOYER'S FIRST REPORT OF INJURY OR FATALITY

Fields marked with an asterisk (*) are required—you cannot submit the form unless these fields are completed.

 
4. Gender*
6. Was employee hired in NH*
18. Date and Time of Injury (mm/dd/yyyy)*
20. Full wages paid on injury date?
29. Has injured returned to work?*
32. Returned at:
35. Was accident caused by injured's failure to use safeguards or follow regulations?*
36. Initial treatment
40. Has injured died, Date of Death (mm/dd/yyyy)*
50. No. of employees
60. The employee will be out of work for 4 or more calendar days
62. Attachments
( 9.5mb limit for all files )
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