REPORTING FORMS

STATEMENT OF FACTS

Employee's Statement of Facts (pdf):  

Delaware requires every employee alleging a work injury to complete all information on the Statement of Facts form for his Employer.  We recommend all Employers have their employees prepare this form on the date of accident as a matter of company policy, sign the form and then place a copy in the employee's personnel file.  The information on this form can be critical to investigate compensability.  A variation of this form is used in death cases.  Our firm also offers a Spanish version for clients with Spanish speaking employees.

FIRST REPORT OF INJURY

Employer's First Report of Injury (pdf):  

Within ten days after an Employer is notified that an industrial accident allegedly injured its employee, the Employer must complete and file the Employer's First Report of Injury with the Industrial Accident Board and send a copy to its Insurer.  Employers who fail to do so are subjected to fines; yet, it is also in Employers' best interest that they make the "first" report rather than someone planning to sue them. To prevent fraud, we strongly urge our clients to sign the form.

SUPPLEMENTAL REPORT

Employer's Supplemental Report of Injury (pdf):  

If Employer's First Report of Injury did not show the injured employee returned to work, an Employer's Supplemental Report of Injury must be completed and filed with the Industrial Accident Board immediately after he does return to work; or at the end of disability when compensation has been paid under an Agreement.  In the event of the employee's death, this report should be filed immediately.

COMPENSATION FORMS

I.A.B. AGREEMENT

Agreement as to Compensation (pdf):  

If the Employer or Insurer agree to accept liability on a claim then the Employer's attorney or Insurer's adjustor must execute this Agreement as to Compensation form with the employee and file it with the Industrial Accident Board for approval.  Never pay on a claim unless the employee first signs this.  No Agreement?  No Award?  No deal.

I.A.B. AGREEMENT (DEATH)

Agreement as to Compensation for Death (pdf):

If the Employer and Insurer agree to accept liability where the employee died as a result of an industrial accident the Insurer or self-insured Employer must complete this Agreement as to Compensation for Death form with the employee's estate and file it with the Industrial Accident Board for approval.   Never pay on a claim unless the employee first signs this.  No Agreement?  No Award?  No deal. 

I.A.B. RECEIPT

Receipt for Compensation Paid (pdf):  

Insurance Carriers and Employers must file this Receipt for Compensation to report to the Industrial Accident Board when the injured employee has received payment for any item covered under Delaware's Workmen's Compensation Law of 1917 as amended.  It is imperative to file this so that the statute of limitations will begin to count down.

Insurer Forms

EXTENSION OF TIME

Extension of Time to Decide Claim (pdf):  

Use this form to request and receive an extension of time from the Industrial Accident Board in order to investigate a claim more fully before making a final determination as to whether they will accept or deny the claim.  If they do ultimately decide to accept the claim, it is imperative that they use the Agreement and Receipt forms below.

NOTICE OF CLAIM DENIAL

Notice of Denial Form (pdf):  

Use this form to notify employees and the Industrial Accident Board that they are denying a claim and the reasons therefor.  Please note that the second to last option should only be selected when denying a claim for additional benefits on a claim for which the Employer previously accepted liability as documented on an I.A.B. Agreement signed by both parties.

OFFER TO ACCEPT CLAIM

Offer to Accept Claim (pdf):  

Use this form to notify the employee that you will offer to accept liability on a claim while making your offer strictly contingent on the employee and a witness signing and returning the I.A.B. Agreement you prepared to memorialize exactly what you will, and will not, accept.  Remember: This is only an offer.  No acceptance?  No deal.

EMPLOYER FORMS

NOTICE OF COVERAGE

Insurance Coverage Status Form (pdf):  

All businesses must submit this form to the Industrial Accident Board and Division of Revenue to notify the State: (1) of their insurance coverage; (2) that they are legally self-insured; (3) that they are exempt from the Workmen's Compensation Law (only businesses engaged in farming or those with no employees); or (4) to allow subcontractors in the construction industry to give proper notice as required by 19 Del. C. § 2311.

MODIFIED DUTY JOB OFFER

Employer's Modified Duty Form (pdf):  

If the Employer can offer a modified duty job to the employee then an Employer's Modified Duty Form should be completed as soon as possible and forwarded to his physician with instructions to indicate whether the job is approved, sign and return the form to the Employer within fourteen days.  If the parties have entered into an Agreement, a copy of this form must accompany the Agreement when filed with the Industrial Accident Board.

COMPENSATION BOND

Certificate of Bond (pdf):  

Always maintain the requisite insurance coverage.  Should a claim be filed against an Employer who has failed to obtain insurance then, after a hearing, the Industrial Accident Board may order the Employer to post a surety bond in an amount fair to the Employer to secure funds for the employee should the claim be held compensable.  After securing the appropriate bond, the Employer and bondsman complete and file this form with the Industrial Accident Board.

OTHER I.A.B. FORMS

U.R. REQUEST FORM

Utilization Review Request Form (pdf):  

Employers or Insurance Carriers may engage in Utilization Review to evaluate the quality, reasonableness and/or necessity of proposed or provided health care services for acknowledged compensable claims.  The Utilization Review company is randomly selected by the Department of Labor after the Employer or Insurance Carrier completes this form and mails it, along with the required documentation, to the Department of Labor pursuant to the instructions found on the second page of this document.

PRETRIAL MEMORANDUM

I.A.B. Pretrial Memorandum (pdf):  

If the parties could not reach an Agreement on a claim (see Agreement forms above) or if they wish to appeal an adverse utilization review finding to the Industrial Accident Board, the petitioner (either the Employer, Insurer or Employee) must complete this Pretrial Memorandum and provide it to the responding party so that both parties can list the issues in dispute and defenses to be raised at hearing.  Once completed by both parties it must be filed with the Industrial Accident Board.

PHYSICIAN'S INJURY REPORT

Physician's Report of Injury (pdf):  

The physician most responsible for the treatment of the employee’s work-related injury shall complete and submit, as expeditiously as possible and not later than 10 days after the date of first evaluation or treatment, a report of the employee's condition and limitations on this form and shall expeditiously provide copies of this report of employee condition and limitations to the employee, the employer and the employer’s insurance carrier, if applicable, as required by 19 Del. C. § 2322E(b).