LeadingAge

Instructions for Completing Employer Report of Industrial Injury/Occupational Disease

  • The link to the CRM Employer Report of  Industrial Injury/Occupational Disease is below.  Clicking on that link will take you to the on-line report of accident.
  • After you click the link, you will need to enter the password you were provided, elsewhere.  If you have forgotten the password, contact LeadingAge and request it.  Note it is case sensitive.
  • Some of the form’s data fields ask for required data.  You will not be permitted to complete the form without including a response to all required data fields.  The purpose for this is to assist you in completing the form with the L&I-required information.
  • Just as with the prior paper claims initiation process, you will need to send supporting documentation for the claim.  We recommend that you scan those documents as a single .pdf file and then attach the scanned file to the electronic form via the browse function at the end of the form.  Examples of types of supporting documentation that should be sent to us includes:
    • Attending Physician-reviewed job analyses of at-injury job or transitional duty job.  These job analyses are contained in the Job Analysis Bank available to you through LeadingAge.
    • Release for Work or Activity Prescription Form (APF)
    • Transitional job offer letter, if appropriate.
    • Employment application.
    • MSDS sheets in cases of chemical exposure.
    • Accident investigation documentation including witness statements, if any.
    • For motor vehicle accidents, copies of the police report.
    • Payroll history for on-call employees, shift differentials and varying schedules.

Access to Online Employer Report of Industrial Injury/Occupational Disease

  • Access the secure online form
  • Access to Online Claim Document Filing for Existing Claims
  • Use the following link to upload documents to a previously-filed claim. To use this link, an Employer Report of Industrial Injury/Occupational Disease claim form should have already been filed. Please scan and file your documents to a single .pdf file for uploading.  Note that you will need to complete the claim identification information on the document uploading form in order to be able to upload your claim documents. The submission form is password protected.  It is the same password that you were provided to access the Employer Report of Industrial Injury/Occupational Disease.
  • Claim Document Submission on Existing Claims