1. FederalEmployer'sIdentificationNumber_________________________________________Dateofhire __________________
2. Nameofemployer____________________________________________________________Phone______________________
3. Mailingaddress___________________________________________________________________________________________________________ Street City State ZIPCode
4. Location,ifdifferentfrommailingaddress_______________________________________________________________________________________ Street City State ZIPCode
5. Natureofbusiness_________________________________ NAICSorS.I.C.Code___________Dept.ordivision___________________________
6. Nameofemployee_________________________________________________________________________________Age______Sex______ First Middle Last7. Homeaddress ___________________________________________________________________________________________________________ Street City State ZIPCode
Birth Employee's Home8. SSN_____________________ date________________ occupation________________________________ phone_________________________9. Dateofinjuryoroccupationaldisease__________________Timeofinjury_________ a.m. p.m. Datereportedtoemployer__________________Datedisabilitybegan__________________Grossaverageweeklywage$_________________
10. Placeofaccidentorlastexposure ____________________________________________________________________________________________ City County State
11. Wasaccidentorlastexposureonemployer'spremises?c YESc NO
12. Howdidaccidentoccur? ___________________________________________________________________________________________________
________________________________________________________________________________________________________________________
13. Whatwasemployeedoingwheninjured?______________________________________________________________________________________
________________________________________________________________________________________________________________________
14. Namesubstanceorobjectthatdirectlycausedinjury*____________________________________________________________________________ ________________________________________________________________________________________________________________________
15. Describeindetailnatureandextentofinjury,indicatepartofbodyinvolved*___________________________________________________________ ________________________________________________________________________________________________________________________
16. Wasworkeradmittedtohospital?c YESc NODate__________________Treatedbyemergencyroomonly?c YESc NO
Hospitalnameandaddress _________________________________________________________________________________________________
17. Nameandaddressofattendingphysicianorclinic _______________________________________________________________________________ ________________________________________________________________________________________________________________________
18. Hasemployeereturnedtoregularduty?c YESc NOLightduty?c YESc NODate_________________________
19. Iscompensationnowbeingpaid?c YESc NODatefirst/initialpayment____________________
20.Weeklycompensationrate$____________________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_____________________________________
OSHA Case or File Number______________________________
KANSASDEPARTMENTOFLABORwww.dol.ks.gov
ACCIDENT REPORT K-WC1101-A(Rev.1-12)
Page1of2
Thereisa$250penaltyforrepeatedfailuretofileaccidentreportswithin28daysofthedatetheemployerisinformedoftheaccident.Submission does not constitute admission of liability.
– SEE INSTRUCTIONS ON PAGE 2 –
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
FOROFFICE
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CAUSE
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0-NOTIMELOST1-TIMELOST2-MEDICAL3-FATAL
InstructionsYoumustanswereveryquestion;failuretoanswerallquestionsmaycausethereporttobereturnedtotheemployer.Returnedaccidentreportsmaycauseadelayofbenefitstotheinjuredemployeesandcouldsubjecttheemployertofines.
Mailorfaxtheoriginalreportonly.IfnotcompletedusingthefillablePDFform,thereportmustbeprintedneatlyinblackinkortypewritten.Ifnotlegible,thereportwillbereturnedwhichwilldelaytimelyprocessing.
Theemployermustsendthisaccidentreporttoitsinsurancecarrier,thirdpartyadministratororpoolassociationasindicatedintheemployer'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 for Questions 14 and 1514:Nametheobjectorsubstancewhichdirectlyinjuredtheemployee.Example:machineorobjectemployee struckorstruckemployee;vapororpoisonemployeeinhaledorswallowed;chemicalsorradiationwhich irritatedemployee'sskin;ifhernia,theobjectemployeewasliftingorpulling;etc.
15:Beasspecificaspossibleindicatingallthatisknownabouttheinjury.Namethepartofbodyinjured.
Definition of an Incapacitating InjuryTheWorkers’CompensationActsetsforthastricttimeframeforfilingaccidentreportswiththedivision.ThecontrollingstatuteisK.S.A.44-557(a),whichreadsasfollows:
(a)itisherebymadethedutyofeveryemployertomakeorcausetobemadeareporttothedirectorofanyaccident,orclaimedorallegedaccident,toanyemployeewhichoccursinthecourseoftheemployee’semploymentandofwhichtheemployerortheemployer’ssupervisorhasknowledge,whichreportshallbemadeuponaformtobepreparedbythedirector,within28days,afterthereceiptofsuchknowledge,ifthepersonalinjurieswhicharesustainedbysuchaccidentsaresufficientwhollyorpartiallytoincapacitatethepersoninjuredfromlabororserviceformorethantheremainderoftheday,shiftorturnonwhichsuchinjuriesweresustained.
Accidentreportsarenotrequiredforeverywork-relatedinjury.Thestatuterequiresareporttobefiledwhentheworker'swholeorpartialincapacitycontinuesbeyondthe"day,turn,orshiftwhichsuchinjuriesaresustained"astheresultofaccident."Incapacity"isnotspecificallydefinedwithinthelaw,butthedivisionbelievesthattheLegislature'sintentwastoreferenceaworker'swholeorpartiallossoftheabilitytoperformhisorherordinaryjobtasks.Whenindoubt,keepinmindthelawcontainsnopenaltyforfilingareportthatultimatelyprovestobeunnecessary.There are penalties, however, for failing to file a report when one was required.Thepenaltiesincludefinesandlimitationsonthedefensestheemployermayassertifaclaimisfiled.
OSHA RecordkeepingTheemployermustcompleteanInjuryandIllnessIncidentReport,OSHAForm301,withinseven(7)daysoflearningthatawork-relatedinjuryorillnesshasoccurred.AccordingtoOSHA'srecordkeepingrule,youmustkeepForm301,oranequivalentsubstituteonfileforfive(5)years.
TolearnmoreaboutOSHA'srecordkeepingrequirementsanddownloadforms,visit:www.osha.gov/recordkeeping/RKforms.html
Page2of2KansasDepartmentofLaborEmployer's Accident ReportK-WC1101-A(Rev.1-12)