Report an Injury for Maine

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*Internet Explorer is not recommended for First Report of Injury submissions*

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

1. Lost time - one or more days*
2. Was employee paid for 1/2 day or more on day of injury?
3. Lost earnings but no lost time*
4. Medical only
6. Occupational disease
9. Correct prior report
22. Did injury or exposure occur on employer's premises?
39. Sex*
49. Does employee work for another employer?
50. Marital status*

51. Date of Injury or Illness*
56. Time of injury
57. Has the employee returned to work?*
63. Was activity part of normal job duties?
65. Hospitalized overnight as inpatient
66. Was the employee treated in the emergency room?
74. Attachment field (medical records)
( 9.5mb limit for all files )