Form 122 - Employers First Report Of Injury Or Illness - 2009 Page 2
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1
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3FRAUD – “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 Labor Commission, Division of Industrial
Accidents, per Sections §34A-2-407 and §34A-3-10B, 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, 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 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 Labor Commission is to receive an original of this report, Worker’s Compensation Insurance
Carrier gets a second copy, the employee gets a third copy, and the employer gets a fourth copy and should
maintain a copy of this report.
*Failure to file this report with the Labor Commission 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), §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, but you must still file the
“Employer’s First Report of Injury or Illness” form with the Labor Commission.
* 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
rd
160 East 300 South, 3
Floor
P O Box 146610
Salt Lake City, Utah 84114-6610
(801) 530-6800 (800) 530-5090
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