First Report of Injury Electronic Submission Application Claims Management Division Application for First Report of Injury Electronic Submission If you are unable to access this application using the free Adobe Acrobat Reader, please contact us for a hard copy of this application at: (717) 772-0621. This application is restricted to employers, workers' compensation insurance companies and third-party administrators (TPAs) to obtain a User ID and Password to submit First Reports of Injury to the Bureau of Workers' Compensation via the Internet. • Employers complete sections A and C. • Insurers and TPAs, complete sections B and C. Upon completion of the appropriate sections, print the application and mail or fax it to: Bureau of Workers' Compensation 1171 S. Cameron St., Room 103 Harrisburg, PA 17104-2501 - or - Fax: (717) 705-1629 Questions? Call (717) 772-0621 or e-mail us at: ra-li-bwc-ereports@state.pa.us NOTE: If you are an Insurer or TPA submitting a significant number of First Reports of Injury to the Bureau of Workers' Compensation, you may wish to consider an Electronic Data Interchange partnership with the Bureau of Workers' Compensation. Please contact us at 717-787-3361 to obtain further information. A. EMPLOYER APPLICATION INFORMATION Name: American LegalNet, Inc. www.FormsWorkflow.com First Report of Injury Electronic Submission Application Address Line 1: Address Line 2: Address Line 3: FEIN: Contact Name: Phone Number: E-Mail Address: Workers' Compensation Insurer Name: Insurer or Self-Insured Bureau Code: Insurer Policy Number: Policy Period From (Month/Day/Year): To (Month/Day/Year): B. INSURER OR THIRD-PARTY ADMINISTRATOR APPLICATION Name: Address Line 1: Address Line 2: Address Line 3: American LegalNet, Inc. www.FormsWorkflow.com First Report of Injury Electronic Submission Application FEIN: PCRB Number: Contact Name: Phone Number: E-Mail Address: Insurer's Bureau Code: If you are a third-party administrator, list the name and Bureau Code of the client(s) on whose behalf you will submit First Reports of Injury: Name Bureau Code 1. 2. 3. 4. If you require additional space, please attach a separate sheet and note such on application. American LegalNet, Inc. www.FormsWorkflow.com First Report of Injury Electronic Submission Application C. SELECTING A USER ID AND PASSWORD 1. Select a User ID for your company and enter it on the following lines. Your User ID must be eight characters in length. 2. Select a Password for your company and enter it on the following lines. Your Password must be eight characters in length. If, for security reasons, you wish to change your User ID and Password, please contact us at the e-mail address or telephone number listed below. It is your responsibility to retain this Password. Failure to do so will require your company to reapply for access. We recommend that insurers and TPAs file a separate application for each branch office or location. Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the PA Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994. Name of Applicant: Title of Applicant: Signature of Applicant: Date: (Month/Day/Year) Upon completion of the appropriate sections, print the application and mail or fax it to: Bureau of Workers' Compensation, 1171 S. Cameron St., Room 103, Harrisburg, PA 17104-2501; Fax: (717) 705-1629 Unless your application has been denied, your User ID and Password should be activated within five business days from the date of receipt of your application. If you cannot access the First Report Submission program within that period, or if you have any questions regarding this application, call the Bureau of Workers' Compensation at 717-772-0621, or e-mail us at: ra-li-bwc-ereports@state.pa.us. American LegalNet, Inc. www.FormsWorkflow.com