New Hampshire Employee Work Injury Notice
NEW HAMPSHIRE EMPLOYEE WORK INJURY NOTICE
Before you send this: N.H. Rev. Stat. § 281-A:19 generally requires notice of injury to the employer within two years of the injury for a benefits claim. If the nature of the injury and its possible relationship to work were not known, the statute has a later-knowledge rule. Record the actual dates below and give notice promptly; do not assume the later-knowledge rule applies without examining the facts.
Notice date: [__/__/____]
To employer or authorized representative: [NAME / TITLE]
Employer name and address: [NAME / ADDRESS]
From employee: [FULL NAME]
Employee contact information: [MAILING ADDRESS / PHONE / EMAIL]
Injury notice
I give notice of an injury that I believe may be related to my work.
Date of injury or work event: [__/__/____]
Worksite and location: [ADDRESS / SPECIFIC PLACE]
What happened or what work exposure occurred: [FACTUAL DESCRIPTION]
Nature of injury and affected body part(s): [DESCRIPTION]
Date I first knew the nature of the injury: [__/__/____]
Date I first knew of its possible relationship to my employment: [__/__/____]
Earlier report to employer, if any: [PERSON / DATE / METHOD, OR "NONE"]
Available records or witnesses, if any: [DESCRIPTION, OR "NONE"]
Please confirm receipt of this notice and identify the person handling the injury report. I will supply additional accurate information requested through the applicable claim process.
Employee signature: ______________________________ Date: [__/__/____]
If submitted by someone on the employee's behalf: [NAME / RELATIONSHIP / CONTACT]
Submitter signature: ______________________________ Date: [__/__/____]
Delivery record — retain with a copy
Recipient and role: [NAME / TITLE]
Method and destination: [HAND DELIVERY / MAIL / ELECTRONIC METHOD AND ADDRESS]
Delivery or confirmed receipt date: [__/__/____]
Proof retained: [ACKNOWLEDGMENT / RECEIPT / EMAIL RECORD / OTHER]
Official source
About this template
- Last updated
- November 4, 2026
- Citations checked
- November 4, 2026
- Jurisdiction
- New Hampshire
- Category
- Employment & HR
Legal authority
- N.H. Rev. Stat. § 281-A:19
Employment documents govern the relationship between a company and its workers, from offer letters and employment agreements through handbooks, performance reviews, and separations. Done right, they set clear expectations, protect against wrongful termination and discrimination claims, and give both sides a record to rely on. Done poorly, they invite lawsuits, agency complaints, and costly disputes.
Not legal advice
This template is provided for informational purposes. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Checked against the law it cites
A reviewer verified this template's legal citations against the official source on November 4, 2026.
N.H. Rev. Stat. § 281-A:19 (employer notice period) (checked November 4, 2026): "Claims for benefits under this chapter shall be barred unless notice of injury is given to the employer within 2 years from the date of the injury"
N.H. Rev. Stat. § 281-A:19 (later knowledge) (checked November 4, 2026): "if the nature of the injury and its possible relationship to the employment are not known to the employee, the time for filing notice shall not begin to run until the earlier of the following:"
Draft your New Hampshire Employee Work Injury Notice in the editor
Answer a few questions, let the AI editor draft each section from your answers, review it, and download Word and PDF. $99 one time, or $249 per month for every document and every Ezel app.