Form 41-101 Wpc - Employer'S Report Of Industrial Injury
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1FOR CARRIER USE ONLY
:
EMPLOYER’S REPORT
MAIL ORIGINAL TO
OF INDUSTRIAL INJURY
IR101
DOC TYPE:
INDUSTRIAL COMMISSION OF ARIZONA
COMPLETE AND MAIL THIS REPORT WITHIN 10 DAYS
P.O. BOX 19070
FROM NOTICE OF ACCIDENT.
FATALITIES MUST BE REPORTED WITHIN 24 HOURS.
PHOENIX, ARIZONA 85005-9070
MAIL COPY TO:
IMPORTANT >>
TO BE COMPLETED
>>>>>>>>>>>>>>>>>>>>>>>>>
BY EMPLOYER
STATE COMPENSATION FUND
An employer must on this form notify his insurance carrier of every
P.O. BOX 33069
injury or disease suffered by an employee, fatal or otherwise, arising
PHOENIX, ARIZONA 85067-3069
out of and in the course of employment.
(602) 631-2000
ARIZONA REVISED STATUTES 23-908 & 23-1061
FAX 1-800-356-4867
OSHA CASE NO.
8. EMPLOYER’S NAME
EMPLOYEE
1. LAST NAME
FIRST NAME
M.I.
2. SOCIAL SECURITY NUMBER
3. BIRTHDATE
9. OFFICE ADDRESS
4. HOME ADDRESS (NUMBER & STREET/MAILING)
APT. #
CITY
STATE
ZIP CODE
5. MARITAL STATUS
6. SEX
SINGLE
MARRIED
DIVORCED
WIDOW/ER
M
F
7. (AREA CODE) TELEPHONE
10. (AREA CODE) TELEPHONE
11. POLICY NO.
12. NATURE OF BUSINESS (MFG, ETC.)
7A. HIRE LOCATION
CITY
STATE
ACCIDENT
13. DATE OF
14. HOUR OF INJURY
15. DATE EMPLOYER NOTIFIED OF INJURY
16. LAST DAY OF WORK AFTER INJURY
17. DATE OF RETURN TO WORK
INJURY
AM
PM
18. EMPLOYEE’S OCCUPATION (JOB TITLE) WHEN INJURED
19. CLASS CODE ON PAYROL REPORT
20. EMPLOYEE’S ASSIGNED DEPT.
DEPT. SUB CODE
DEPT. NO.
22. ADDRESS OR LOCATION OF ACCIDENT
CITY
COUNTY
STATE
ZIP CODE
23. ON EMPLOYER PREMISES?
24. NATURE OF INJURY (SCRATCH, CUT, BRUISE, ETC.)
FATAL?
25. PART OF BODY INJURED
SIDE INJURED
YES
NO
YES
NO
RT
LF
BOTH
26. ATTENDING PHYSICIAN, IF KNOWN (NAME)
ADDRESS (STREET, CITY, STATE & ZIP CODE)
(AREA CODE) TELEPHONE
27. IF HOSPITALIZED, HOSPITAL NAME
ADDRESS (STREET, CITY, STATE & ZIP CODE)
28. IF VALIDITY OF CLAIM IS DOUBTED, STATE REASON
29.
WAS WORKER IN YOUR
EMPLOY WHEN INJURED?
YES
NO
CAUSE OF
ACCIDENT
31. SPECIFY MACHINE, TOOL, SUBSTANCE, OR OBJECT MOST CLOSELY CONNECTED WITH
32.
WHAT WAS EMPLOYEE DOING WHEN ACCIDENT OCCURRED (LOADING TRUCK, WALKING
ACCIDENT
DOWN STAIRS, ETC.)?
33. IF ANOTHER PERSON NOT IN COMPANY EMPLOY CAUSED ACCIDENT, GIVE NAME AND ADDRESS
IMPORTANT WAGE
34. DATE OF LAST HIRE
35. GIVE EMPLOYEE’S WAGE STATUS AS APPLICABLE
36. WAS EMPLOYEE PAID FOR DATE OF INJURY?
DATA>>>>>>>>>>>>
$
PER
HR.
DAY
WK.
MO.
YES
NO
IF YES, AMOUNT
$
>
37. WAS EMPLOYEE HIRED FOR
38. NUMBER OF DAYS PER WEEK
39. HOURS PER DAY EMPLOYEE WORKED
40. DOES EMPLOYEE OWN PART OR ALL OF BUSINESS
EMPLOYEE
COMPANY
PERMANENT EMPLOYMENT?
From
AM
PM
YES
NO
USUALLY
USUALLY
YES
NO
WORKED
WORKS
Thru
AM
PM
41. NUMBER OF MONTHS EMPLOYMENT
42. WAS EMPLOYEE ON OVERTIME WHEN
43.
IF EMPLOYEE EARNS EXTRA PAY FOR OVERTIME, WHAT IS
PER HOUR
AVAILABLE DURING THE YEAR
INJURED?
BASIS OF PAYMENT?
$
YES
NO
OVER
HOURS
44. NUMBER OF HOURS OF OVERTIME
45. IS EMPLOYEE FURNISHED
VALUE
CONSIDERED NORMAL PER WEEK
LODGING
BOARD/MEALS
BOTH
$
PER WK.
PER MO.
PER YR.
IMPORTANT
IF EMPLOYEE IS PAID OTHER THAN FIXED
46. ACTUAL GROSS EARNINGS OF EMPLOYEE FOR THE 30 CALENDAR DAYS PRECEDING INJURY
>>>>>>>>>>
WEEKLY OR MONTHLY SALARY
(EXAMPLE IF INJURED APRIL 8, GIVE EARNINGS FROM MARCH 9 THRU APRIL 7)
COMPLETE ITEMS 46 THRU 52
$
47. GROSS WAGES OF EMPLOYEE DURING 12 MONTHS PRECEDING INJURY
48. IF EMPLOYEE WORKED LESS THAN 12 MONTHS, SHOW GROSS WAGES FROM DATE OF HIRE
THROUGH DAY PRIOR TO INJURY
FROM
THRU
$
FROM
THRU
$
49. DATE OF LAST WAGE INCREASE IF WITHIN
50. WAGE BEFORE INCREASE
51. WAGE AFTER INCREASE
52.
GROSS EARNINGS FROM DATE OF
12 MONTHS PRIOR TO INJURY
INCREASE THRU DAY PRIOR TO INJURY
$
$
$
AUTHORIZED
DATE
AUTHORIZED SIGNATURE
TITLE
SIGNATURE
41-101 WPC 3/96
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