Instructions for Form ERD-991 "First Report of Injury or Occupational Disease" - Montana

This document contains official instructions for Form ERD-991, First Report of Injury or Occupational Disease - a form released and collected by the Montana Department of Labor and Industry.

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First Report of Injury or Occupational Disease
Instructions
Workers’ compensation insurance is a state-required insurance, which provides medical benefits, wage compensation and
rehabilitation to workers injured on the job. Severe penalties can be assessed against an uninsured employer. Neither general
liability nor health and accident insurance policies are substitutes for workers’ compensation insurance.
The worker and employer may complete this form together or they may each submit a separate form.
Injured Worker’s Instructions
Workers have two reporting requirements: 1) Notify your employer of an on-the-job injury within 30 days of its occurrence and 2)
Complete this form as a claim for compensation. The form must be signed and submitted to the employer’s insurer or the
Department of Labor and Industry within 12 months of the accident.
The form must be submitted for all injuries in order to
protect your right to benefits in the event a seemingly minor injury develops into a more serious condition.
Complete a report of the injury
Be thorough in completing all areas except the gray shaded areas. It is important to you that we have complete information.
You must provide your Social Security Number (SSN). This is a mandatory requirement that is permitted under Section 7(a) the
Privacy Act of 1974 because the Montana Department of Labor and Industry’s forms, prescribed by department rules in
existence prior to January 1, 1975, have required disclosure of the SSN. The SSN is used as a key identifier of the claimant
and is needed because of the number of persons who have similar names and birth dates, and whose identities can only be
distinguished by the SSN. Use extra sheets of paper if needed. Type or print with a ballpoint pen.
To ensure that workers’ compensation systems will not be disrupted, the Health Insurance Portability and Accountability
Act of 1996 (HIPAA), Public Law 104-191, 42 USC 1301, et. seq., permits the disclosure of protected health care
information pursuant to the provisions of state laws regarding workers’ compensation. 45 CFR 164.512(l) states:
“Standard: Disclosures for workers’ compensation: A covered entity may disclose protected health information as
authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other
similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.”
Employer’s Instructions
Montana law requires employers to complete this form within six days after notice of every on-the-job accident, injury and/or
occupational disease (OD) by a worker. Ensure all areas are completed except the gray shaded areas, which your insurer will
complete. It is important that we have complete information.
Type or print with a ballpoint pen. If you are completing with WORD software, you may tab through the fields. If the injured
worker is available to do so, they may file a claim for workers’ compensation by completing and signing their portions of this
form. You may then complete the employer section.
Send the original immediately to your workers’ compensation insurer. If you don’t know whom your insurer is, contact the
Montana Department of Labor and Industry (see below). SEND THIS FORM WITHIN THE 6-DAY LIMIT EVEN IF THE
WORKER IS NOT AVAILABLE TO SIGN. This form must be submitted even if the employer questions whether or not the
reported injury and/or OD are job-related. Additional sheets of paper may be attached, if needed to fully explain all conditions
concerning the injury and/or OD.
The United States Department of Labor, OSHA, requires employers to maintain a record of occupational injuries in the
employer’s office. Please copy the completed form for your records.
Insurer/Adjuster
(not submitting electronically)
Please complete all gray shaded areas, and mail a completed copy immediately to the Montana Department of Labor and
Industry at the address shown below. Boxes that have been BOLDED are mandatory in order to file this report. If you wish to
file First Report information electronically, please contact the Employment Relations Division.
Presumptive Claims (ex: firefighter)
For filing a presumptive claim, especially for retirees, the department recommends working directly with the insurer or the
department, as the existing claim form was designed based on a national standard that does not currently include claims of this
nature. Following is a couple of helpful hints for filling out the form for retiree presumptive claims.
1) Employee/Volunteer Dates of Service can be entered into the Date of Hire and Last Day Worked fields on the existing form.
Use Date of Hire for the begin date of service and Last Day Worked for the end date of service.
2) The Date of Diagnosis can be entered into the Date of Injury field on the form.
3) Fire agency worked/volunteered for should be entered into the Employer Name field on the form.
4) The Accident Description Field on the form can be used to collect miscellaneous data such as date of last physical, number
of years as a firefighter or any other data the insurer feels is pertinent to adjudicating the claim. This data element allows for
up to 512 characters.
The Insurer and/or the department is here for any questions or to provide assistance in filing these types of claims.
First Report of Injury or Occupational Disease
Instructions
Workers’ compensation insurance is a state-required insurance, which provides medical benefits, wage compensation and
rehabilitation to workers injured on the job. Severe penalties can be assessed against an uninsured employer. Neither general
liability nor health and accident insurance policies are substitutes for workers’ compensation insurance.
The worker and employer may complete this form together or they may each submit a separate form.
Injured Worker’s Instructions
Workers have two reporting requirements: 1) Notify your employer of an on-the-job injury within 30 days of its occurrence and 2)
Complete this form as a claim for compensation. The form must be signed and submitted to the employer’s insurer or the
Department of Labor and Industry within 12 months of the accident.
The form must be submitted for all injuries in order to
protect your right to benefits in the event a seemingly minor injury develops into a more serious condition.
Complete a report of the injury
Be thorough in completing all areas except the gray shaded areas. It is important to you that we have complete information.
You must provide your Social Security Number (SSN). This is a mandatory requirement that is permitted under Section 7(a) the
Privacy Act of 1974 because the Montana Department of Labor and Industry’s forms, prescribed by department rules in
existence prior to January 1, 1975, have required disclosure of the SSN. The SSN is used as a key identifier of the claimant
and is needed because of the number of persons who have similar names and birth dates, and whose identities can only be
distinguished by the SSN. Use extra sheets of paper if needed. Type or print with a ballpoint pen.
To ensure that workers’ compensation systems will not be disrupted, the Health Insurance Portability and Accountability
Act of 1996 (HIPAA), Public Law 104-191, 42 USC 1301, et. seq., permits the disclosure of protected health care
information pursuant to the provisions of state laws regarding workers’ compensation. 45 CFR 164.512(l) states:
“Standard: Disclosures for workers’ compensation: A covered entity may disclose protected health information as
authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other
similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.”
Employer’s Instructions
Montana law requires employers to complete this form within six days after notice of every on-the-job accident, injury and/or
occupational disease (OD) by a worker. Ensure all areas are completed except the gray shaded areas, which your insurer will
complete. It is important that we have complete information.
Type or print with a ballpoint pen. If you are completing with WORD software, you may tab through the fields. If the injured
worker is available to do so, they may file a claim for workers’ compensation by completing and signing their portions of this
form. You may then complete the employer section.
Send the original immediately to your workers’ compensation insurer. If you don’t know whom your insurer is, contact the
Montana Department of Labor and Industry (see below). SEND THIS FORM WITHIN THE 6-DAY LIMIT EVEN IF THE
WORKER IS NOT AVAILABLE TO SIGN. This form must be submitted even if the employer questions whether or not the
reported injury and/or OD are job-related. Additional sheets of paper may be attached, if needed to fully explain all conditions
concerning the injury and/or OD.
The United States Department of Labor, OSHA, requires employers to maintain a record of occupational injuries in the
employer’s office. Please copy the completed form for your records.
Insurer/Adjuster
(not submitting electronically)
Please complete all gray shaded areas, and mail a completed copy immediately to the Montana Department of Labor and
Industry at the address shown below. Boxes that have been BOLDED are mandatory in order to file this report. If you wish to
file First Report information electronically, please contact the Employment Relations Division.
Presumptive Claims (ex: firefighter)
For filing a presumptive claim, especially for retirees, the department recommends working directly with the insurer or the
department, as the existing claim form was designed based on a national standard that does not currently include claims of this
nature. Following is a couple of helpful hints for filling out the form for retiree presumptive claims.
1) Employee/Volunteer Dates of Service can be entered into the Date of Hire and Last Day Worked fields on the existing form.
Use Date of Hire for the begin date of service and Last Day Worked for the end date of service.
2) The Date of Diagnosis can be entered into the Date of Injury field on the form.
3) Fire agency worked/volunteered for should be entered into the Employer Name field on the form.
4) The Accident Description Field on the form can be used to collect miscellaneous data such as date of last physical, number
of years as a firefighter or any other data the insurer feels is pertinent to adjudicating the claim. This data element allows for
up to 512 characters.
The Insurer and/or the department is here for any questions or to provide assistance in filing these types of claims.
Further Information
Department of Labor & Industry
Employment Relations Division
Workers’ Compensation Claims Assistance Bureau
PO Box 8011
Helena MT 59604-8011
(406) 444-6543
http://erd.dli.mt.gov
The United States Department of Labor, OSHA, requires employers to maintain a record of occupational injuries in the employer’s office.
3/16/2021 - DAR
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