Fillable Form 122E EMPLOYERS FIRST REPORT OF INJURY OR (CompWest)

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Form 122E EMPLOYERS FIRST REPORT OF INJURY OR (CompWest)

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Form 122E EMPLOYER’S FIRST REPORT OF INJURY OR ILLNESS Rev 10/2019
160 East 300 South 3
rd
Floor P.O. Box 146610 Salt Lake City, Utah 84114-6610
Office: (801)-530-6800 Fax: (801)-530-6804 Toll Free: (800)-530-5090 www.laborcommission.utah.gov
TO BE COMPLETED BY EMPLOYER WITH ORIGINAL SENT TO INSURANCE CARRIER AND COPY SENT TO INJURED WORKER
INJURED WORKER INFORMATION:
Name:
Phone:
Address:
City: State: Zip:
Social Security Number:
Date of Birth:
Marital Status:
Sex: Male
Female
Unknown
Occupation / Job Title:
Date Hired:
Employment Status:
Number of Dependents:
Wage: Wage Period:
Daily Weekly Monthly
Full Pay for Day of Injury: Yes
No
Number of Days Worked per Week:
EMPLOYER INFORMATION:
Business Name:
Phone:
Employer Contact:
Phone:
Mailing Address:
City: State: Zip:
Employment Address:
City: State: Zip:
Employer FEIN:
INSURANCE INFORMATION:
Carrier:
Phone:
Carrier Address:
City: State: Zip:
Policy / Self-Insured Number:
Policy Period:
OCCURRENCE/TREATMENT:
Date of Injury / Disease:
Time of Injury:
Date Employer Notified:
Nature:
Body Part:
Cause:
Last Day Worked:
Date Disability Began:
Date Returned to Work:
Fatality: Yes No
Date of Death:
Date Administrator Notified:
Address of Occurrence:
City: State: Zip:
Premises: Employer’s Other Description:
Accident Description:
Provider Injured Worker Received Care From:
Provider Address :
City: State: Zip:
Treating Physician:
Phone:
Initial Treatment: No Medical Treatment Minor: By Employer Minor: Clinic/Hospital Emergency Care
Hospitalized- 24 Hours Future Major Medical/Lost Time Anticipated
Witnesses: Yes No If yes list their names and phone number:
For your protection, it is required by Utah Law to give notice that workers’ compensation fraud is a crime. See next page for full
fraud statement.
Form 122E EMPLOYER’S FIRST REPORT OF INJURY OR ILLNESS Rev 10/2019
160 East 300 South 3
rd
Floor P.O. Box 146610 Salt Lake City, Utah 84114-6610
Office: (801)-530-6800 Fax: (801)-530-6804 Toll Free: (800)-530-5090 www.laborcommission.utah.gov
INSTRUCTIONS TO THE EMPLOYER
PLEASE NOTE:
The
filing of this form does not admit liability or fault. However, failure to file this report with the insurance
carrier and provide a copy to the injured worker can result in a citation and civil penalty for each violation as
per §34A-2-407(8), U.C.A.
The insurance carrier is to receive the original of this form. The injured worker shall then receive a copy
along with their rights and obligations of the Utah’s Workers’ Compensation Act (Form 100). The employer
should keep a copy for their records. The Labor Commission, Division of Industrial Accidents, will receive an
electronic copy from the insurance carrier. The electronic copy of this form is private information and only
released to parties of the claim.
In or
der to dispute the validity of the injured worker’s claim, contact the insurance carrier or claim
administrator for more information.
All fields on this form are required. Please complete this form entirely and do not leave any blank fields. This
form will be returned and additional information will be requested if it is not properly completed. If you, the
employer, need assistance to complete the form contact your workers’ compensation insurance carrier or
claims administrator.
Rule R612-200-1(A)(2) Except for injuries treated only by first aid, an employer shall report each employee
work injury within 7 days after receiving initial notice of the injury, as follows:
a. An em
ployer that has obtained workers' compensation insurance shall report the injury to its
insurance carrier.
b. An em
ployer that has received Division authorization to self-insure shall report the injury to its
claims administrator.
c. An em
ployer that has failed to obtain worker's compensation coverage shall report the injury by
contacting the Division directly.
3. An employer has notice of a work injury upon the earliest of:
a. Obs
ervation of the injury;
b. Ver
bal or written notice of the injury from any source; or
c. Receipt of any other information sufficient to warrant further inquiry by the employer.
FRAUD WARNING:
Any person who knowingly presents false or fraudulent underwriting information, files, claim for disability
compensation, medical benefits, health care fees, or other professional services are of guilty of a crime and
may be subject to fines and confinement in state prison.
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Form 122E EMPLOYERS FIRST REPORT OF INJURY OR (CompWest)

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Completed 29 July 2021

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