Injury Reporting for Employers Employers may complete the section below to report an injury to WCA. Employers may also download Form 5020 by clicking on the following link. The form can then be completed and faxed, e-mailed or mailed to WCA to report a work injury. Click here to download Form 5020 or you may complete the following to report an injury online:   Online Injury Reporting Form Employer Name Employee Name Social Security Number Date of Birth Home address Phone number () - Sex Occupation Date of Hire How many hours per week does employee usually work? Employment status (full-time, part-time, temp, etc.) Gross wages/salary Other payments not reported as wages or salary? Date of Injury Time of Injury Time employee began work If employee died, date of death Was employee unable to work for at least one full day after injury? Date last worked Date returned to work Is employee still off work? Was employee paid full days wages for date of injury or last day worked? Is salary being continued? Date of employer's knowledge of injury Date employee was provided with Claim Form Specific Injury and part of body injured Location where injury occurred County Did injury happen on employer's premises? Department where injury occurred Were other workers injured? Equipment being used when injury occurred Specific activity the employee was performing when injured How did the injury occur? Name and address of physician Was employee hospitalized overnight? If yes, give phone number of hospital () - Was employee treated in the emergency room? Does employer dispute injury? If employer disputes injury, please state the reason Completed by (Name and title)