Kansas > Workers Compensation
Employers Report Of Accident K-WC 1101-A - Kansas
| Employers Report Of Accident Form. This is a Kansas form and can be used in Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
KANSASDEPARTMENTOFLABOR www.dol.ks.gov Page1of2 ACCIDENT REPORT K-WC1101-A(Rev.1-12) SEE INSTRUCTIONS ON PAGE 2 Thereisa$250penaltyforrepeatedfailuretofileaccidentreportswithin28daysofthedatethe employerisinformedoftheaccident.Submission does not constitute admission of liability. OSHA Case or File Number______________________________ Mail or fax ORIGINAL report to: DivisionofWorkersCompensation 401SWTopekaBlvd.,Suite2 Topeka,KS66603-3105 Fax:(785)296-4216 Direct questions or comments to: Toll-free(800)332-0353 1. FederalEmployer'sIdentificationNumber ________________________________________ Dateofhire __________________ _ 2. Nameofemployer ___________________________________________________________Phone______________________ _ 3. Mailingaddress___________________________________________________________________________________________________________ City State ZIPCode Street 4. Location,ifdifferentfrommailingaddress_______________________________________________________________________________________ Street City State ZIPCode 5. Natureofbusiness_________________________________ NAICSorS.I.C.Code___________Dept.ordivision___________________________ 6. 7. Nameofemployee_________________________________________________________________________________Age______Sex______ First Middle Last Homeaddress ___________________________________________________________________________________________________________ City State ZIPCode Street COUNTY FOR OFFICE USE Birth Employee's Home 8. SSN_____________________ date________________ occupation________________________________ phone_________________________ 9. Dateofinjuryoroccupationaldisease__________________Timeofinjury_________ a.m. p.m. Datereportedtoemployer__________________Datedisabilitybegan__________________Grossaverageweeklywage$_________________ CAUSE 10. Placeofaccidentorlastexposure ____________________________________________________________________________________________ City County State 11. Wasaccidentorlastexposureonemployer'spremises?c YESc NO 12. Howdidaccidentoccur? ___________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ NATURE EVERITY S 0- NOTIMELOST 1- TIMELOST 2- MEDICAL 3- FATAL 13. Whatwasemployeedoingwheninjured?______________________________________________________________________________________ ________________________________________________________________________________________________________________________ 14. Namesubstanceorobjectthatdirectlycausedinjury *____________________________________________________________________________ ________________________________________________________________________________________________________________________ SOURCE 15. Describeindetailnatureandextentofinjury,indicatepartofbodyinvolved*___________________________________________________________ ________________________________________________________________________________________________________________________ 16. Wasworkeradmittedtohospital?c YESc NODate__________________Treatedbyemergencyroomonly?c YESc NO Hospitalnameandaddress _________________________________________________________________________________________________ MEMBER 17. Nameandaddressofattendingphysicianorclinic _______________________________________________________________________________ ________________________________________________________________________________________________________________________ 18. Hasemployeereturnedtoregularduty?c YESc NOLightduty?c YESc NODate_________________________ 19. Iscompensationnowbeingpaid?c YESc NODatefirst/initialpayment____________________ 20.Weeklycompensationrate$____________________Isfurthermedicalaidneeded?c YESc NOc UNKNOWN 21. Didemployeedie?c YESc NOIfYES,givedateofdeath___________________(Fileamendedreportwithin28daysifdeathsubsequentlyoccurs.) 22. Name(s)andaddress(es)ofdependents(deathcasesonly)________________________________________________________________________ ________________________________________________________________________________________________________________________ 23. Insurancecarrierandthirdpartyadministrator___________________________________________________________________________________ Address ________________________________________________________________________________Phone__________________________ StreetCityStateZIPCode Policynumber____________________________________________Nameofagent___________________________________________________ Claimnumber___________________________________ Nameofclaimrepresentative________________________________________________ 24. Dateofreport_________________Completedby______________________________________ Title_____________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Employer's Accident Report K-WC1101-A(Rev.1-12) KansasDepartmentofLabor Page2of2 Youmustanswereveryquestion;failuretoanswerallquestionsmaycausethereporttobereturnedtothe employer.Returnedaccidentreportsmaycauseadelayofbenefitstotheinjuredemployeesandcouldsubjectthe employertofines. Mailorfaxtheoriginalreportonly.IfnotcompletedusingthefillablePDFform,thereportmustbeprintedneatly inblackinkortypewritten.Ifnotlegible,thereportwillbereturnedwhichwilldelaytimelyprocessing. Theemployermustsendthisaccidentreporttoitsinsurancecarrier,thirdpartyadministratororpoolassociation asindicatedintheemployer'sinsurancecontract.The employer is responsible for submitting the original report to the Division of Workers Compensation within 28 days of the date the employer is informed of the accident. Instructions *Instructions for Questions 14 and 15 14:Nametheobjectorsubstancewhichdirectlyinjuredtheemployee.Example:machineorobjectemployee struckorstruckemployee;vapororpoisonemployeeinhaledorswallowed;chemicalsorradiationwhich irritatedemployee'sskin;ifhernia,theobjectemployeewasliftingorpulling;etc. 15:Beasspecificaspossibleindicatingallthatisknownabouttheinjury.Namethepartofbodyinjured. TheWorkers'CompensationActsetsforthastricttimeframeforfilingaccidentreportswiththedivision.The controllingstatuteisK.S.A.44-557(a),whichreadsasfollows: (a)itisherebymadethedutyofeveryemployertomakeorcausetobemadeareporttothe directorofanyaccident,orclaimedorallegedaccident,toanyemployeewhichoccursinthe courseoftheemployee'semploymentandofwhichtheemployerortheemployer'ssupervisor hasknowledge,whichreportshal
|
|||||||
