Fillable Form 122 EMPLOYERS FIRST REPORT OF INJURY OR (National American Insurance Company)

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Form 122 EMPLOYERS FIRST REPORT OF INJURY OR (National American Insurance Company)

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Form 122 EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS
(Filing this form is not an admission of liability for the claim.)
Carrier/Administrator Claim Numbe
r
OSHA Log Number
Report Purpose Code
Jurisdiction Jurisdiction Claim Number
Insured Report Number
Employer (Name & Address Include Zip)
Location Number
G
E
N
E
R
A
L
Industry Code Employer FEIN
Employer’s Location Address (If Different)
Phone Number
CARRIER/CLAIMS ADMINISTRATOR
Policy Period __________
To __________
Carrier (Name, Address & Phone Number)
Check If Appropriate
Self-Insurance
Claims Administrator (Name, Address & Phone Number)
Carrier FEIN Policy/Self-Insured Number Administrator FEIN
C
A
R
R
I
E
R
C
L
A
I
M
S
A
D
M
I
N
Agent Name and Code Number
EMPLOYEE/WAGE
Date of Birth Social Security Number
Date Hired State of Hire
Occupation / Job Title
Name (Last, First, Middle) Address (incl. Zip)
Employment Status
Claimant may need an interpreter: Yes No
Language _______________
Sex
Male
Female
Unknown
E
M
P
L
O
Y
E
E
Phone
Number of Dependents
Marital
Status
Unmarried/
single/Divorced
Married
Separated
Unknown
NCCI Class Code
W
A
G
E
Rate _______________ Day Month
Per:
Week Other
Number of Days Worked/Week
Full Pay For Day of Injury Yes No
Did Salary Continue Yes No
OCCURRENCE/TREATMENT
Time Employee AM
Began Work ___________ PM
Date of Injury/Illness
Time of Occurrence
AM Last Work Date
_________________
PM
Date Employer
Notified
Date Disability
Began
Contact Name/Phone Number
Type of Injury/Illness
Part of Body Affected
Did Injury/Illness Exposure Occur on Employer’s Premises?
Yes No
Type of Injury/Illness Code
Part of Body Affected Code
Department Or Location Where Accident or Illness Exposure Occurred 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?
YES No
Yes NO
O
C
C
U
R
R
E
N
C
E
Physician/Health Care Provider (Name & Address) Hospital (Name & Address)
Initial Treatment
No Medical Treatment
Minor: By Employer
Minor: Clinic/Hospital
Emergency Care
Hospitalized – 24 hrs
Future Major Medical/Lost Time
Anticipated
OTHER
Witnesses (Name & Phone Number)
O
T
H
E
R
Date Administrator Notified
Date Prepared
Preparer’s Name & Title
Phone Number
Official Form 122 Revised 10/14
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
Print Form
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 insurance carrier, per Sections §34A-2-407 and
§34A-3-10B, R612-200-1 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 except
first-aid R612-100-2, 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 electronic 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 Worker’s Compensation Insurance Carrier gets an original copy, the employee gets a second copy,
and the employer gets a third copy and should maintain a copy of this report. The insurance carrier will send
the Labor Commission an electronic copy of the injury report.
*Failure to file this report with the insurance carrier 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), R612-200-1, §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, and you must still file the
“Employer’s First Report of Injury or Illness” form with them. They will then submit it to the Labor
Commission electronically. If the employer has no workers’ compensation insurance this form must be
submitted to the Labor Commission directly.
* Reminder: Inform your injured employee of his/her rights and obligations (as outlined on the
back of the employee’s copy) of Utah’s Workers’ Compensation Act.
For Additional Information please contact:
State of Utah – Labor Commission
Division of Industrial Accidents
160 East 300 South, 3
rd
Floor
P O Box 146610
Salt Lake City, Utah 84114-6610
(801) 530-6800 (800) 530-5090
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.”
EMPLOYEE INFORMATION
• INJURY/ILLNESS REPORT
: A report of your injury/occupational illness must be made with your employer.
If a report of injury is not filed with your employer or the Labor Commission, Division of Industrial Accidents,
within 180 days of the date of your injury/illness, you may lose the right to ever file a claim for workers’
compensation benefits for that injury or illness.
• EMPLOYER’S PHYSICIAN
: If your employer has a company physician or designated clinic for industrial
accidents, you MUST see the company physician first, or you may not be eligible for workers’ compensation
benefits. After you have been seen by your employer’s physician, you have the right to choose one
treating
physician.
• MEDICAL COOPERATION
: You must cooperate with your employer or the insurance carrier in following
prescribed medical treatment in order to return to work as quickly as possible.
• TRAVEL REIMBURSEMENT
: You may be eligible for travel reimbursement to and from approved medical
care. You will need to keep records. Contact your insurance carrier regarding travel expenses.
• REEMPLOYMENT ASSISTANCE
: You may be eligible for reemployment assistance if you are unable to
return to work due to an industrial injury. Contact your insurance carrier or the Labor Commission, Division of
Industrial Accidents, for further information.
• MEDICAL EXPENSES
: You are entitled to have all reasonable medical expenses paid that are a result of the
injury or illness.
• COMPENSATION BENEFITS
: You are entitled to 66-2/3 of your wages up to 100% of the state average
weekly wage (as of the date of your injury) after 3 days from the date of your injury, if a physician states you are
totally unable to work.
□ If you have sustained a permanent impairment
due to the industrial injury or disease, you are entitled to
compensation based on the impairment rating as determined by a physician.
□ If you are permanently totally
disabled from working due to the industrial injury, you may need to apply
at the Labor Commission, Division of Industrial Accidents, for a hearing to determine if benefits are due.
• ADDITIONAL ASSISTANCE
: If you are unable to work due to an industrial injury and meet the program’s
requirements, you may be eligible for other assistance. Agencies you may wish to contact:
□ Department of Workforce Services for food stamps, cash assistance, medical assistance, or employment
assistance.
□ Social Security for total disability benefits.
• UNEMPLOYMENT BENEFITS
: If you are able to work, but have been terminated from your job, you need to
apply at the nearest Department of Workforce Services employment office within 90 calendar days after you are
released from full-time work by your doctor.
Contact your insurance carrier if problems occur during your injury regarding payment of medical
bills or compensation benefits. If you need to know who your employer’s insurance carrier is, you may
ask your employer or contact the Labor Commission, Division of Industrial Accidents.
More information is found on our Website laborcommission.utah.gov
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Completed 29 July 2021

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