Fill - Free fillable Workers Compensation First Report of Injury or Illness PDF form

Iowa Workers’ Compensation – FIRST REPORT OF INJURY OR ILLNESS Jurisdiction Code______________ Jurisdiction Claim Number_______________

Claim Administrator Name: Claim Representative Business

Phone Number:

Insurer Name (if different than claim administrator):

Claim Administrator Claim Number:

Insurer FEIN:

CLAIM ADMIN

Mailing Address, City, State, & Postal Code:

Claim Administrator FEIN:

Claim Type Code:

Employer Name: Employer FEIN:

Insured Report Number:

Industry Code:

Employer Type Code:

__ Employer (E)

__ Lessor (L)

Physical Address, City, State, & Postal Code: Mailing Address, City, State, & Postal Code:

Insured Location Number: Employer UI Number:

EMPLOYER

Nature of Business: Employer Contact Name and Business Phone Number:

Coverage Effective Date:

POLICY

Insured Name (parent company if different than employer): Insured FEIN:

Insured Postal Code: Policy/Contract Number:

Coverage Expiration Date:

Self Insurance License/

Certificate Number:

Gender: Tax Filing Status (check one):

Employee Name (First, Middle, Last, & Suffix): Date of Birth:

__ Male (M) ____ Single (A) ____ Married/Filing Joint (C)

__ Female (F) ____ Single/Head of Household (B) ____ Married/Filing Separate(D) Date of Hire:

Educational Level (grade completed): _______ [GED = 12]

Employment Status (check one): Employee ID Number (check one):

Mailing Address, City, State, & Postal Code:

ID # ______________________ Phone Number (include area code):

Marital Status: (check one)

___ Unmarried (U)

___ Married (M)

___ Separated (S)

Occupation Description:

Employee’s Authorization to

Release the Following:

Manual Classification Code:

Medical Records __ yes

EMPLOYEE

Department Where Regularly Worked:

____ Piece Worker

____ Volunteer

____ Seasonal

____ Apprenticeship/Full-Time

____ Apprenticeship/Part-Time

____ Regular Employee/Full-Time

____ Part-Time

____ Other

____ Social Security Number

____ Employment VISA Number

____ Passport Number

____ Green Card

____ Employee ID Assigned by Jurisdiction

Social Security Number __ yes

Average Wage $ ___________ (check one):

Salary Continued In Lieu of Compensation: ___ yes ___ no Employee Number of Dependents: __________

___ hourly ___ daily ___ semi-monthly ___ monthly

___ bi-weekly ___ annual ___ weekly

Full Wages Paid for Date of Injury: ___ yes ___ no

Employee Number of Exemptions: ___________ (check

one)

___ Entitled

WAGE

Number of Days Regularly Worked Per Week: _______ Discontinued Fringe Benefits: $_____________

___ Withholding

Describe the nature of the injury. (ex. amputation, burn, cut, fracture):

_____________________ Date of Injury

_____________________ Date Employer Had Knowledge of the Injury

_____________________ Date Claim Administrator Had Knowledge of the Injury

_____________________ Initial Date Last Day Worked

_____________________ Initial Return to Work Date (if applicable)

_____________________ Employee Date of Death (if applicable)

_____________________ Time of Injury

_____________________ Time Employee Began Work

Pre-Existing Disability Code:

Part(s) of body directly affected by the injury or illness. (ex. hand, arm, circulatory system):

___ Yes

___ No

___ Unknown

Accident Premises Code:

___ Employer (E)

Describe the events that caused the injury. (ex. fell, operating machinery, chemical exposure):

___ Lessee (L)

___ Other (X)

Accident Site Organization Name:

Name the object or substance that directly injured the employee. (ex. knife, floor, acid, oil):

Accident Site Street, City, State, & Postal Code:

Accident Location Narrative (if no street address):

Specify activity the employee was engaged in when the event occurred. (ex. cutting metal plate for flooring) Indicate if activity was part of normal duties:

ACCIDENT/INJURY

Accident Site County/Parish: Witness Name & Business Phone Number:

Initial Treatment Code (check one):

___ no medical treatment (0)

___ minor/on-site treatment (1)

Initial Medical Provider Name:

___ clinic/hospital visit (2)

Managed Care Organization Name or ID Number:

___ emergency care (3)

___ hospitalization > 24 hours (4)

MEDICAL

___ future medical treatment/lost time anticipated (5)

Initial Medical Provider Physical Address, City, State, & Postal Code:

ICD Primary Diagnostic Code

(if known):

Preparer’s Name & Title: Preparer's Company Name: Phone Number: Date:

Gallagher Bassett Services

14000 Quail Springs Parkway

Oklahoma City, OK 73134

Indian Hills Community College

525 Grandview Ave.

Ottumwa, IA 52501

Community college

Same as employer

Same

(800) 943-7244

38-3365500

42-0923689

Same

Zeke Flick (641) 683-5282

821600 0617357

July 1 annually

IMPACC

42-1332533

This section is to provide information valuable in handling this claim. POSTING REQUIREMENTS

The Iowa Occupational Safety and Health Act requires that employees be

informed of the job safety and health protection provided under the Act. The poster, “Safety

and Health Protection on the Job,” is to be used for this purpose, and must be posted in a

prominent place in the establishment to which the employees usually report to work. The

poster briefly states the intent and coverage of the Act and the responsibilities of employers

and employees to maintain safe and healthful working conditions.

The Iowa Occupational Safety and Health Act

The following is a summary of the recordkeeping, reporting and posting

responsibilities of employers under Iowa’s Occupational Safety and Health Act.

RECORDKEEPING REQUIREMENTS

Regulations issued under the Iowa Occupational Safety and Health Act of

1972 require establishments subject to the Act to maintain records of recordable

occupational injuries and illness. Such records must consist of: (a) a log and summary of

occupational injuries and illnesses and (b) a supplementary record of each occupational

injury and illness.

EMPLOYERS WHO MUST KEEP OSHA RECORDS

Employers with 11 or more employees (at any one time in the previous

calendar year) in the following industries must keep OSHA records. The industries are

identified by name and by the appropriate Standard Industrial Classification (SIC) code:

LOG AND SUMMARY OF OCCUPATIONAL INJURIES AND ILLNESSES.

Each recordable occupational injury and occupational illness must be entered on a log and

summary of cases (0SHA Form No. 200) as early as practicable but no later than six working

days after receiving information that a recordable case has occurred. A multi-unit employer

may maintain the log and summary of occupational injuries and illnesses at a place other

than the establishment if there is a copy of the log and summary available in the

establishment complete and current to a date within 45 calendar days. If an equivalent of

OSHA Form No 200 is used, such as a printout from data-processing equipment, the

information shall be as readable and comprehensible to a person not familiar with the data-

processing equipment as the OSHA Form No. 200 itself. Logs must be kept current and

retained for 5 years following the end of the calendar year to which they relate.

• Agriculture, forestry, and fishing (SIC’s 01-02 and 07-09)

• Oil and gas extraction (SIC 13 and 1477)

• Construction (SIC’s 15-17)

• Manufacturing (SIC’s 20-39)

• Transportation and public utilities (SIC’s 41-42 and 44-49)

• Wholesale trade (SIC’s 50-51)

• Building materials and garden supplies (SIC 52)

• General merchandise and food stores (SIC’s 53 and 54)

• Hotels and other lodging places (SIC 70)

• Repair services (SIC’s 75 and 76)

SUPPLEMENTARY RECORD OF OCCUPATIONAL INJURIES AND

ILLNESSES. To supplement the Log and Summary of Occupational Injuries and Illnesses,

each employer must have available a record for each occupational injury or illness at each

establishment within six working days after receiving information that a recordable case has

occurred, OSHA Form No. 101 may be used for this purpose. State of Iowa Form No. 14-

0001 [(IAIABC Form 1.2 (12/98)], workers' compensation or other reports are acceptable as

records if they contain the information required on OSHA Form No 101. These records must

be available in the establishment without delay and at reasonable times for examination by

representatives of the Iowa Division of Labor Services, the U.S. Department of Labor and

the U.S. Department of Health, Education and Welfare. The records must be maintained for

a period of not less than 5 years following the end of the calendar year to which they relate.

• Amusement and recreation services (SIC 79)

• Health services (SIC 80), and

• State and local government (Above SIC ‘s plus 91-97).

If employers in any of the industries listed above have more than one

establishment with combined employment of 11 or more employees, records must be kept

for each individual establishment.

All employers, including small employers and those in exempted SIC’s,

must continue to meet the requirement to report fatalities or multiple (3 or more)

hospitalizations and all occupational injuries or occupational illnesses that result in a

workers' compensation case.

If an employer is notified in writing by the Bureau of Labor Statistics about

having been selected to participate in a statistical survey, such employer, including small

employers, and those in exempted SIC’s, must maintain a log and summary of all

occupational injuries and illnesses for that year. The notification will contain the necessary

form and instructions to comply with the survey requirements.

The Iowa Workers’ Compensation Act

The following is a summary of the recordkeeping and reporting

responsibilities of employers under the Iowa Workers’ Compensation Act.

RECORDS AND REPORTS

Every employer shall keep a record of all injuries sustained

by employees in the course of their employment resulting in incapacity

for longer than one day. An employer with notice or knowledge of an

injury which temporarily disables an employee for more than three (3)

days or results in permanent total disability, permanent partial disability

or death is required to electronically file a report with the Workers'

Compensation Commissioner within four (4) days from such event when

such injury is alleged by the employee to have been sustained in the

course of employment.

All books, records, and payrolls of an employer are required to be open for

inspection by the Workers' Compensation Commissioner for purposes of administration of

the Iowa Workers’ Compensation Act.

The Workers' Compensation Commissioner may require an employer to

appear and show cause why the employer should not be subject to a civil penalty of

$1,000.00 per occurrence for failure to comply with the reporting or inspection requirements.

Upon hearing, if the facts indicate, the commissioner may enter an order requiring payment

of such penalty. Unless voluntarily paid, the commissioner may petition the district court for

entry of judgment on the order. The employer’s insurance carrier shall be responsible in the

same manner and to the same extent as the employer when a report of injury has been

submitted to the employer’s insurance carrier and not filed by them with the Workers'

Compensation Commissioner.

The employer is required to furnish to an employee, on request, one

statement of earnings, wages, or salary for the year preceding the injury. An employer may

be subject to a civil penalty of $1000.00 per offense for refusal to furnish such wage

statement.

ANNUAL SUMMARY. Each employer subject to the recordkeeping

requirements must prepare a summary of the occupational injury and illness experience of

the employees in each of the employer’s establishments at the end of each year based on

the information contained in the log and summary of occupational injuries and illnesses for

the particular establishment. OSHA Form No. 200 shall be used for this purpose. The

summary shall be signed and posted in a place accessible to the employees no later than

February 1 and shall remain in place until March 1. For employees who do not report to

work at a single establishment, or who do not report to any fixed establishment on a regular

basis, employers shall satisfy the posting requirement by presenting or mailing a copy of the

annual summary during the month of February to all such employees who receive pay during

that month. Summaries must be retained for 5 years following the end of the calendar year

to which they relate.

EMPLOYEES NOT IN FIXED ESTABLISHMENTS. Employers of

employees engaged in physically dispersed operations such as occur in construction,

installation, repair or service activities who do not report to any fixed establishment on a

regular basis but are subject to common supervision may satisfy the recordkeeping

provisions with respect to such employees by:

(a) Maintaining the required records for each operation or group of

operations which is subject to common supervision (field superintendent, field supervision,

etc.) in an established central place;

(b) Having the address and telephone number of the central place available

at each worksite; and

hours to provide information from the records maintained there by telephone and by mail.

(Note: This regulation does not automatically apply to all

construction, installation, repair or service activities. If in doubt about applicability to

your operations, contact the Iowa Division of Labor Services.)

Records for personnel who do not primarily report or work at a single

establishment, and who are generally not supervised in their daily work, such as traveling

salespersons, technicians, engineers, etc., shall be maintained at the location from which

they are paid or the base from which personnel operate to carry out their activities.

REPORTING REQUIREMENTS

Regulations issued under the Iowa Occupational Safety and Health Act

require all employers subject to the Act to report to the Iowa Workers' Compensation

Commissioner any occupational injury or illness which temporarily disables an employee for

more than three days or which results in permanent total disability, permanent partial

disability, or death. The report must be filed electronically in conformity with EDI

requirements with the Iowa Division of Workers' Compensation within four days from such

event when the injury or illness is alleged by the employee to have been sustained in the

course of the employee’s employment. A report to the Iowa Division of Workers'

Compensation is considered to be a report to the Iowa Division of Labor Services. The Iowa

Division of Workers' Compensation shall forward all such reports to the Iowa Division of

Labor Services.

In addition, employers must report to the Iowa Labor Commissioner within 8

hours each accident or health hazard that results in one or more fatalities or hospitalization

of three or more employees.

Those establishments selected to participate in the annual Occupational

Injuries and Illnesses Survey will be required to prepare a report (OSHA Form No 200-S)

based on entries contained on the Log and Summary of Occupational Injuries and Illnesses.

INSTRUCTIONS

An employer with notice or knowledge of an injury which temporarily disables an employee for more than THREE (3) days or results in permanent total

disability, permanent partial disability or death is required to electronically file a first report of injury with the Iowa DIVISION OF WORKERS' COMPENSATION within FOUR (4)

days from such event when such injury is alleged by the employee to have been sustained in the course of the employee’s employment. A report to the Iowa DIVISION OF

WORKERS' COMPENSATION is considered to also be a report to the Iowa DIVISION OF LABOR SERVICES. The Iowa DIVISION OF WORKERS' COMPENSATION forwards

the report to the Iowa Division of Labor Services. Employers should report ALL injuries to their insurance carrier or third party administrator

. ALL REPORTS MUST BE FILLED

IN COMPLETELY AND SIGNED. PLEASE TYPE OR PRINT LEGIBLY.

This form contains all items requested on OSHA form No 101, “Supplementary Record of Occupational Injuries and Illness.”

THE INFORMATION PROVIDED WILL BE OPEN FOR PUBLIC INSPECTION UNDER Iowa Code § 22.11.

Iowa Form 14-0001 (11/04)

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