Accident Report Form - Kansas Department Of Labor -2013
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2KANSAS DEPARTMENT OF LABOR
Page 1 of 2
Send this completed form to your
ACCIDENT REPORT
insurer, third party administrator
or pool association for submission
K-WC 1101-A (Rev. 10-13)
electronically to the Division of
– SEE INSTRUCTIONS ON PAGE 2 –
Workers Compensation.
Direct questions or comments to:
There is a $250 penalty for repeated failure to file accident reports within 28 days of the date the
Toll free (800) 332-0353
employer is informed of the accident. Submission does not constitute admission of liability.
OSHA Case or File Number
______________________________
1. Federal Employer's Identification Number _ ________________________________________ Date of hire __________________
( )
2. Name of employer _ ___________________________________________________________ Phone ______________________
3. Mailing address __________________________________________________________________________________________________________
Street
City
State
ZIP
FOR
4. Location, if different from mailing address ______________________________________________________________________________________
OFFICE
Street
City
State
ZIP
USE
5. Nature of business_________________________________ NAICS or S.I.C. Code___________ Dept. or division ___________________________
6. Name of employee _________________________________________________________________________________ Age______ Sex______
First
Middle
Last
7. Home address __________________________________________________________________________________________________________
COUNTY
Street
City
State
ZIP
Birth
Employee's Home
( )
8. SSN _____________________ date ________________ occupation ________________________________ phone _________________________
CAUSE
9. Date of injury or occupational disease__________________ Time of injury_________ a.m. / p.m.
Date reported to employer __________________ Date disability began __________________ Gross average weekly wage $_________________
NATURE
10. Place of accident or last exposure ____________________________________________________________________________________________
City
County
State
11. Was accident or last exposure on employer's premises? c YES c NO
S EVERITY
12. How did accident occur? ___________________________________________________________________________________________________
0 - NO TIME LOST
________________________________________________________________________________________________________________________
1 - TIME LOST
13. What was employee doing when injured? ______________________________________________________________________________________
2 - MEDICAL
________________________________________________________________________________________________________________________
3 - FATAL
*
14. Name substance or object that directly caused injury
____________________________________________________________________________
________________________________________________________________________________________________________________________
SOURCE
*
15. Describe in detail nature and extent of injury, indicate part of body involved
___________________________________________________________
________________________________________________________________________________________________________________________
MEMBER
16. Was worker admitted to hospital? c YES c NO Date__________________ Treated by emergency room only? c YES c NO
Hospital name and address _________________________________________________________________________________________________
17. Name and address of attending physician or clinic _______________________________________________________________________________
________________________________________________________________________________________________________________________
18. Has employee returned to regular duty? c YES c NO Light duty? c YES c NO Date_________________________
19. Is compensation now being paid? c YES c NO Date first/initial payment____________________
20. Weekly compensation rate $____________________ Is further medical aid needed? c YES c NO c UNKNOWN
21. Did employee die? c YES c NO If YES, give date of death___________________
(File amended report within 28 days if death subsequently occurs.)
22. Name(s) and address(es) of dependents (death cases only) ________________________________________________________________________
________________________________________________________________________________________________________________________
23. Insurance carrier and third party administrator ___________________________________________________________________________________
( )
Address ________________________________________________________________________________ Phone __________________________
Street
City
State
ZIP
Policy number____________________________________________ Name of agent___________________________________________________
Claim number___________________________________ Name of claim representative________________________________________________
24. Date of report_________________ Completed by______________________________________ Title_____________________________________
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