WC-100 (2/13) - Employer's Basic Report of Injury (fill-in form)

Form WC-100 utilizes Optical Character Recognition (OCR) to scan data.  In order for the OCR function to work properly, a submitted form must be identical to the WC-100 provided on the Workers’ Compensation Agency website, including but not limited to language, block space and positioning, font and dimension.  When data is input into the form, Arial 10 point font must be used, with each field limited to one line of data.

Therefore, this form can’t be handwritten and must be either mailed or submitted through the Data Exchange Gateway (DEG). The DEG application provides further information.

Forms not complying with these requirements will be rejected and returned unprocessed.

Select for Form WC-100