Form 41-101b - Instructions To Complete The Employer'S Report Of Industrial Injury

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The State Fund recommends
INSTRUCTIONS TO COMPLETE THE
An incomplete or delayed
reporting an injury within 24 hours.
EMPLOYER'S REPORT OF INDUSTRIAL INJURY
report could increase costs.
When you are notified of a work-related injury, the law requires you to report it within
The Call Center representative will take the information and send a copy of the report
10 days using an Employer's Report of Industrial Injury form. Please fill out this form
for your signature.
accurately and completely, and verify all facts concerning the accident before filing the
report. This form is not to be completed by your employee. Filling out this form does
not admit liability for the alleged injury. A fatality must be reported by telephone within
24 hours to the Arizona Division of Occupational Safety and Health (602/542-5795).
Please file promptly so we may protect your interests.
Employee Information
(Items 1 through 7)
Use worker's name as it appears on your payroll, and be sure to include the worker's
Social Security number.
Employer Information
(Items 8 through 12)
These items identify you to the State Fund and to the Industrial Commission of
Arizona. To ensure proper identification, show your firm's name as listed on your
workers' compensation insurance policy.
Accident Information
(Items 13 through 33)
These items detail the accident which caused the injury. Attach separate sheet if
necessary. Verify facts with the injured worker, the supervisor and all witnesses. If
you doubt the validity of the claim, state your reasons under item 28. All of this
information helps determine the compensability of the claim. Fill out item 32 if a third
party possibly caused the accident.
Wage Information
(Items 34 through 52)
The wage portion must be completed if the injured employee is off work, or is
expected to miss, eight or more calendar days. Wage information is needed to
establish the amount of compensation benefits.
Authorized Signature
It is necessary for the employer's or the authorized agent's signature to appear at the
bottom of the report, together with the agent's title and the date.
Mailing Employer's Report of Industrial Injury Form
It is vital to mail the completed copies of the Employer's Report of Industrial Injury
form to the proper place.
1. MAIL ORIGINAL COPY TO:
2. MAIL ONE COPY TO:
Industrial Commission of AZ
State Compensation Fund
P.O. Box 19070
P.O. Box 33069
Phoenix, Arizona 85005-9070
Phoenix, Arizona 85067
3. RETAIN ONE COPY FOR YOUR FILES.
For Quicker Filing
• You may fax the initial report to 1-800-356-4867, or
• Phone in your request to the Call Center at (602) 631-2300 or 1-800-231-1363.
41-101B WPC REV. 2/97

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