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() -
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
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)