Filing this form is not an admission of liability. You must report a claim to your insurer whenever anyone believes that a work related injury or illness that requires medical care or lost time from work has occurred. If the claimed injury wholly or partially incapacitates the employee for more than  three calendar days, the claim must be made on this form and reported to your insurer within ten days. Your insurer may require you to file it sooner. Failure to file within the ten days may result in penalties. Self-insured employers have 14 days to file this form with the Department of Labor and Industry (Department). It is important to file this form quickly t allow your insurer time to investigate the claim. Your insurer will forward a copy of this form to the Department, if necessary.