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ND WSI SFN 2828 2007-2024 free printable template

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1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 Telephone 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331
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How to fill out North Dakota WSI injury:

01
Obtain the necessary forms from the North Dakota Workers' Compensation Bureau or download them from their website.
02
Provide accurate and detailed information about the injured worker, including their name, address, and contact information.
03
Describe the nature and details of the injury, including how it occurred and any contributing factors.
04
Provide information about medical treatment received, including the names of healthcare providers, dates of treatment, and any relevant medical records or documentation.
05
Include details about the employer, such as the company name, address, and contact information.
06
Provide information about the injured worker's job duties and responsibilities at the time of the injury.
07
Include any witness statements or documentation that may support the injury claim.
08
Submit the completed forms to the North Dakota Workers' Compensation Bureau within the designated timeframe.

Who needs North Dakota WSI injury:

01
North Dakota workers who have suffered a work-related injury or illness.
02
Employers who are required by law to provide workers' compensation insurance for their employees.
03
Healthcare providers and medical professionals who are involved in the diagnosis, treatment, and documentation of work-related injuries.

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North Dakota Workers’ Safety and Insurance (WSI) requires all employers in the state to report workplace injuries and illnesses. Employers are responsible for filing reports within 24 hours of the incident and must submit a completed form to WSI within seven days.
The information required to be reported on a North Dakota Workers’ Compensation Injury Report includes the date of injury, time of injury, place of injury, description of injury, name of injured worker, name of employer, name of treating physician, and the name of the inspector who investigated the claim.
North Dakota Workforce Safety & Insurance (WSI) is a state agency that provides worker's compensation insurance to employees who are injured or become ill as a result of their job in North Dakota. WSI covers medical expenses, lost wages, and rehabilitation services for workers injured on the job, and aims to ensure that injured workers receive the necessary benefits and support they need.
To fill out a North Dakota WSI (Workforce Safety and Insurance) injury form, follow these steps: 1. Obtain the necessary form: Visit the North Dakota WSI website and locate the specific injury form required for your situation. There may be different forms for different types of injuries or claims. 2. Provide your personal information: Fill in your name, address, phone number, and email address at the top of the form. Include your Social Security number and the date of the injury. 3. Provide employer information: Enter the name and address of your employer, as well as any contact information they may require. 4. Describe the injury: Provide a detailed description of the injury, including the date, time, and location of the incident. Explain how the injury occurred, the body parts affected, and any contributing factors. 5. Provide medical information: List any healthcare providers or facilities you visited for treatment, including their names, addresses, and phone numbers. Include the dates of each visit and the nature of the treatment received. 6. Attach supporting documentation: If you have any medical records, bills, or other relevant documents related to your injury, make copies and attach them to the form. This can help support your claim. 7. Submit the form: Once you have completed all sections of the form and attached any necessary documentation, double-check for accuracy and sign the form. 8. Send the form: Depending on the instructions provided, you may be required to mail or fax the form to the WSI office. Ensure you send it to the correct address or number provided on the form or WSI website. It is always recommended to consult the North Dakota WSI website or contact their customer service directly for any specific instructions or additional requirements for your injury claim.
WSI stands for Workforce Safety & Insurance, which is the sole provider of workers' compensation insurance in North Dakota. The purpose of North Dakota WSI Injury is to provide medical and wage loss benefits to workers who sustain job-related injuries or diseases. It aims to ensure that injured workers receive necessary medical treatment, rehabilitation, and compensation, helping them recover and return to work. Additionally, it also protects employers by limiting their liability for workplace injuries and promoting workplace safety.
In North Dakota, the penalty for late filing of a Workers' Compensation (commonly referred to as WSI - Workforce Safety and Insurance) injury claim may result in the loss of certain benefits. According to the North Dakota Administrative Code, a claim for benefits must be filed within one year from the date of injury or within two years from the last payment of compensation or medical benefits related to the injury, whichever is later. If a claim is filed after these deadlines, the injured employee may lose the right to receive ongoing medical treatment and disability benefits. However, there are exceptions to this rule for situations where the employer has knowledge of the injury or has undertaken some form of action related to the injury. It is important for the injured employee to notify their employer about the injury as soon as possible, and to file a claim with WSI within the designated time frames to avoid potential penalties and delays in receiving benefits.
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