
Claims Assistance
Have a claim to file or questions regarding an outstanding claim? We can help!
Filing an Employers First Report of Injury Form
To complete a First Report of Injury Form, please complete the live document below or email a completed document to NHHCT's third-party administrator, NHMTA Services, Inc. Please do not submit directly to NH Department of Labor, all forms must be submitted to NHMTA Services, Inc. for processing and they will electronically file the report for you.
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Employees must notify any and all injuries to a supervisor immediately. Injuries must be reported to NHMTA Services, Inc. within five (5) calendar days of notification. Failure to do so may result in the assessment of a civil penalty to the employer of up to $2,500. Please note that the “Date Employer Notified of Injury” is the date used by the Department of Labor in calculating the five day reporting requirement.
Important Notes Regarding Filing a First Report of Injury Form:​​​
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Complete the form in its entirety, indicating N/A in the boxes not applicable to the claim.
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Indicate whether or not the employee has returned to work, and if so, at what date.
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Include employee's correct mailing address and phone number.
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When completing the “Industry Code” box please select one of the following industry codes:
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3100 - FoodProduction​
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5800 - Eating & Drinking Establishments
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7000 - Hotels & Motels, Sporting, Recreational, Camps, Trailer Parks, & campsites
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7900 - Amusement &Recreational Services
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Retain a copy for your records.​
Claims & Loss Prevention Staff
Claims Adjuster
Christy Marirea
Contact for assistance with or to submit First Report of Injury Forms.
(603) 415-8317
Director of Managed Care & WC Programs
Wendy Skillings
​Contact for questions pertaining to any claim and loss run reports.
(603) 415-8327
Claims Assistant
Julia Dumais
Contact for assistance with or to submit First Report of Injury Forms.
(603) 415-8326
Director of Safety & Loss Control
MaryGrace Johansen
Contact for safety audits and loss prevention consultations.
(603) 415-8402
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