Workers' Compensation - First Report of Injury Form and Instructions (COUNTY PAID EMPLOYEES)


In the event of a work-related injury/illness to a County Paid Employee, the supervisor should:

  • Take care of the employee. If the injury is an emergency, dial 911.
  • Report the claim within 24 hours.
    Fax: 866.814.5595
    Telephone: 866.206.5851
  • Gather the information below before reporting the claim. The first three items are provided for you. Accident Fund can help you select the best medical care provider. They will work with you, the medical provider and your employee to help ensure a safe return to work whenever possible. The claim will be filed with the appropriate regulatory authority for you, if necessary.
    • State of injury: IOWA (or other if working out-of-state) 
    • Employer name: Iowa State Agricultural Extension District 
    • Accident Fund policy or account number: Policy #WCV 6021276 
    • Employee’s supervisor name and phone number
    • Claim reported by who; job title; phone number
    • Location of injury (if employer has multiple locations)
    • Date accident was reported to employer
    • Date of injury; time of injury
    • Last day worked
    • Employee full name; address; phone number (home and work)
    • Employee gender, social security number, date of birth
    • Employee occupation
    • Employee date of hire
    • How did accident occur? Description
    • Type of injury (i.e., broken? sprain?) and body part injured
    • Will employee be off work? Expected return to work date
    • Employee ability to return to work?
    • Was employee referred for care? Where? (phone number) 


You can download this information in PDF format: CountyEmployeeWorkersComp.pdf