Utah > Workers Compensation
Employers First Report Of Injury Or Illness 122 - Utah
| Employers First Report Of Injury Or Illness Form. This is a Utah form and can be used in Workers Compensation . |
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Form 122 G E N E R A L C L A I M S A D M I N EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS (Filing this form is not an admission of liability for the claim.) Carrier/Administrator Claim Number OSHA Log Number Jurisdiction Insured Report Number Employer's Location Address (If Different) Jurisdiction Claim Number Print Form Employer (Name & Address Include Zip) Report Purpose Code Location Number Phone Number Industry Code Employer FEIN CARRIER/CLAIMS ADMINISTRATOR Carrier (Name, Address & Phone Number) Policy Period __________ To _________ Check If Appropriate Self-Insurance Policy/Self-Insured Number Claims Administrator (Name, Address & Phone Number) C A R R I E R Carrier FEIN Agent Name and Code Number Administrator FEIN E M P L O Y E E EMPLOYEE/WAGE Name (Last, First, Middle) Address (incl. Zip) Date of Birth Sex Male Female Claimant may need an interpreter: Language _______________ Phone Yes No Married Unknown Separated Number of Dependents Unknown Full Pay For Day of Injury Did Salary Continue AM Last Work Date _________________ Date Employer Notified Part of Body Affected Yes Yes Date Disability Began No No Social Security Number Marital Status Unmarried/ single/Divorced Date Hired State of Hire Occupation / Job Title Employment Status NCCI Class Code W A G E Rate _______________ Per: Day Week Month Other Number of Days Worked/Week OCCURRENCE/TREATMENT Time Employee Began Work AM Date of Injury/Illness Time of Occurrence PM Contact Name/Phone Number PM Type of Injury/Illness O C C U R R E N C E Did Injury/Illness Exposure Occur on Employer's Premises? Yes No Department Or Location Where Accident or Illness Exposure Occurred Type of Injury/Illness Code Part of Body Affected Code All Equipment, Materials, or Chemicals Employee Was Using When Accident Or Illness Exposure Occurred Work Process The Employee Was Engaged In When Accident Or Illness Exposure Occurred Specific Activity The Employee Was Engaged In When The Accident Or Illness Exposure Occurred Cause Of Injury Code How Injury or Illness / Abnormal Health Condition Occurred, Describe the Sequence of Events and Include Objects or Substances that Directly Injured The Employee or Made The Employee Ill Date Return(ed) to Work If Fatal, Give Date of Death Were Safeguards Or Safety Equipment Provided? Were They Used? Physician/Health Care Provider (Name & Address) Hospital (Name & Address) YES YES NO NO Initial Treatment No Medical Treatment Minor: By Employer Minor: Clinic/Hospital Emergency Care Hospitalized 24 hrs Future Major Medical/Lost Time Anticipated O T H E R OTHER Witnesses (Name & Phone Number) Date Administrator Notified Date Prepared Preparer's Name & Title Phone Number Official Form 122 Revised 2/09 State of Utah Labor Commission Division of Industrial Accidents 160 East 300 South P O. Box 146610 Salt Lake City, UT 84114-6610 Telephone: (801) 530-6800 FAX: (801) 530-6804 Toll Free: (800) 530-5090 www.laborcommission.utah.gov For your protection Utah Law requires notice that worker's compensation fraud is a crime. Please see back of this form for the full fraud statement American LegalNet, Inc. www.FormsWorkFlow.com FRAUD "Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison." INSTRUCTIONS TO EMPLOYER The Employer's First Report of Injury or Illness must be submitted to the Labor Commission, Division of Industrial Accidents, per Sections §34A-2-407 and §34A-3-10B, Utah Code Annotated (U.C.A.). 1997. Each employer shall file the report within seven days after the occurrence, or the employee's notification of the same, which results in medical treatment by a physician, loss of consciousness, loss of work, restriction of work, or transfer to another job. Each employer shall file a subsequent report with the commission of any previously reported injury; or occupational disease that later resulted in death. Also, for your information, Section §34A-6-301(3)(b)(ii) states that each employer shall, within 8 hours of occurrence, notify the Division of Occupational Safety and Health, at (801) 530-6901 or (800) 530-5090, of any; work related fatality; disabling, serious, or significant injury; or occupational disease incident. A serious injury includes; amputation, fractures of major bones (both simple and compound), and hospitalization for medical treatment. * All information requested on this form is of vital importance. Please answer all items in detail in order to avoid additional correspondence or the return of this report for completion. Do not enter data in the shaded areas. * The box titled "OSHA Log Number" must be filled in with the employer assigned Case Number from OSHA's new 300 Injury Log. The Case Number needs to reflect the year of the injury for example, your first injury in 2002 should reflect the first injury and the year 00/02 with the next injury being 00202, etc. * Please provide WAGE information. This information is needed by the insurance company for paying the correct amount on a claim. * The injury report on file with the Labor Commission, Division of Industrial Accidents, is private information and is only released to parties to the claim. * Please make sure the EMPLOYER NAME is correct, as well as your FEIN # (Federal Tax ID Number). The employer's name should be the same as reported to The Department of Workforce Services and as it appears on your WORKERS' COMPENSATION insurance policy. * The Labor Commission is to receive an original of this report, Worker's Compensation Insurance Carrier gets a second copy, the employee gets a third copy, and the employer gets a fourth copy and should maintain a copy of this report. *Failure to file this report with the Labor Commission or failure to provide the employee with a copy of the report, is a Class C misdemeanor and can also result in a citation and a civil penalty for each violation as per §34A-2-407(7), §34-a-30108(7), §34A-6-302, and §34A-6-307, U.C.A. *If you dispute the validity of this claim you need to contact your insurance carrier, but you must still file the "Employer's First Report of Injury or Illness" form with the Labor Commission. * Reminder: Inform your injured employee of his/her rights and obligations (as outlined
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