Iowa Workers’ Compensation – FIRST REPORT OF INJURY OR ILLNESS Jurisdiction Code______________ Jurisdiction Claim Number_______________
© IAIABC FORM 1.2 (12/98)
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
__
no
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
__
no
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
42-0923689
Same
Zeke Flick (641) 683-5282
821600 0617357
XX
July 1 annually
July 1 annually
IMPACC
42-1332533
XX
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
(c) Having personnel available at the central place during normal business
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)