Form 122 - Employers First Report Of Injury Or Illness - 2010
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EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS
Form 122
(Filing this form is not an admission of liability for the claim.)
Employer (Name & Address Include Zip)
Carrier/Administrator Claim Number
OSHA Log Number
Report Purpose Code
G
E
Jurisdiction
Jurisdiction Claim Number
N
Insured Report Number
E
R
Employer’s Location Address (If Different)
Location Number
A
Industry Code
Employer FEIN
Phone Number
L
CARRIER/CLAIMS ADMINISTRATOR
C
Carrier (Name, Address & Phone Number)
Policy Period __________
Claims Administrator (Name, Address & Phone Number)
L
C
A
To __________
A
I
R
M
Check If Appropriate
R
S
Self-Insurance
I
E
A
Carrier FEIN
Policy/Self-Insured Number
Administrator FEIN
R
D
M
Agent Name and Code Number
I
N
EMPLOYEE/WAGE
E
Name (Last, First, Middle) Address (incl. Zip)
Date of Birth
Social Security Number
Date Hired
State of Hire
M
Sex
Marital
Occupation / Job Title
P
Male
Status
Unmarried/
single/Divorced
Employment Status
L
Female
O
Married
Claimant may need an interpreter:
Yes
No
NCCI Class Code
Y
Unknown
Language _______________
Separated
E
Phone
Number of Dependents
E
Unknown
W
Rate _______________
Day
Month
Number of Days Worked/Week
Full Pay For Day of Injury
Yes
No
A
Per:
G
E
Week
Other
Did Salary Continue
Yes
No
OCCURRENCE/TREATMENT
Time Employee
AM
Date of Injury/Illness
Time of Occurrence
AM
Last Work Date
Date Employer
Date Disability
Began Work ___________
PM
_________________
Notified
Began
PM
Contact Name/Phone Number
Type of Injury/Illness
Part of Body Affected
Did Injury/Illness Exposure Occur on Employer’s Premises?
Type of Injury/Illness Code
Part of Body Affected Code
Yes
No
O
Department Or Location Where Accident or Illness Exposure Occurred
All Equipment, Materials, or Chemicals Employee Was Using When
C
Accident Or Illness Exposure Occurred
C
U
Specific Activity The Employee Was Engaged In When The Accident Or Illness
Work Process The Employee Was Engaged In When Accident Or Illness
R
Exposure Occurred
Exposure Occurred
Cause Of Injury Code
R
How Injury or Illness / Abnormal Health Condition Occurred, Describe the Sequence of Events and Include Objects or Substances that Directly Injured The
E
Employee or Made The Employee Ill
N
Date Return(ed) to Work
If Fatal, Give Date of
Were Safeguards Or Safety Equipment Provided?
YES
No
C
Death
E
Were They Used?
Yes
NO
Physician/Health Care Provider (Name & Address)
Hospital (Name & Address)
Initial Treatment
No Medical Treatment
Minor: By Employer
Minor: Clinic/Hospital
Emergency Care
Hospitalized – 24 hrs
Future Major Medical/Lost Time
Anticipated
O
OTHER
T
Witnesses (Name & Phone Number)
H
E
Date Administrator Notified
Date Prepared
Preparer’s Name & Title
Phone Number
R
Official Form 122
Revised 2/10
State of Utah ● Labor Commission ● Division of Industrial Accidents
160 East 300 South ● P O. Box 146610 ● Salt Lake City, UT 84114-6610 ● Telephone: (801) 530-6800
FAX: (801) 530-6804 ● Toll Free: (800) 530-5090 ●
For your protection Utah Law requires notice that worker’s compensation fraud is a crime. Please see back of this form for the full fraud statement
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