Form K-Wc 1101-A - Employer'S Report Of Accident - 2006
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1
2EMPLOYER'S REPORT OF ACCIDENT
DO NOT WRITE
OSHA Case or File Number
Division of Workers Compensation
Submit
______________________________
IN THIS SPACE
DIVISION OF WORKERS COMPENSATION
original
There is a $250 penalty for repeated failure to file Accident Reports
800 SW JACKSON STE 600
report only
within 28 days of the employer's receipt of knowledge of the accident.
TOPEKA KS 66612-1227
READ ATTACHED INSTRUCTIONS BEFORE COMPLETING THIS FORM.
COUNTY
1.
Federal Employer's Identification Number _________________________________________ Date of Hire:____________________________________
2.
Name of Employer ____________________________________________________________ Telephone Number (_________)__________________
CAUSE
3.
Mailing Address__________________________________________________________________________________________________________
Street
City
State
Zip Code
4.
Location, if different from mailing address________________________________________________________________________________________
Street
City
State
Zip Code
NATURE
5.
Nature of Business___________________________
NAICS or S.I.C. Code_________________
Dept. or Division ________________________
6.
Name of Employee ____________________________________________________________________________________ Age______ Sex______
First
Middle
Last
SEVERITY
7.
Home Address _______________________________________________________________________________________________________________
O - NO TIME LOST
Street
City
State
Zip Code
1 - TIME LOST
Birth
Employee's
Home Phone
2 - MEDICAL
8.
Soc. Sec. #________________________ Date________________ Occupation_________________________ Number (_______)________________
3 - FATAL
9.
Date of Injury or Occupational Disease___________________________________________________ Time of Injury_________________A.M./ P.M.
SOURCE
Date reported to employer__________________
Date Disability Began__________________
Gross Average Weekly Wage $_______________
10. Place of Accident or last exposure ______________________________________________________________________________________________
City
County
State
MEMBER
11. Was accident or last exposure on employer's premises?
YES
NO
12. How did accident occur? ______________________________________________________________________________________________________
DO NOT WRITE
___________________________________________________________________________________________________________________________
IN THIS SPACE
13. What was employee doing when injured? ________________________________________________________________________________________
___________________________________________________________________________________________________________________________
14. Name substance or object that directly caused injury ______________________________________________________________________________
___________________________________________________________________________________________________________________________
15. Describe in detail nature and extent of injury, indicate part of body involved ___________________________________________________________
___________________________________________________________________________________________________________________________
16. Was worker admitted to hospital?
YES
NO
Date______________________ Treated by emergency room only?
YES
NO
Hospital name & address ______________________________________________________________________________________________________
17. Name and address of attending physician or clinic _________________________________________________________________________________
___________________________________________________________________________________________________________________________
18. Has employee returned to regular duty?
YES
NO
Light duty?
YES
NO
Date________________________
19. Is compensation now being paid?
YES
NO
Date first/initial payment_______________________________________________
20. Weekly compensation rate $_____________________________ Is further medical aid needed?
YES
NO
UNKNOWN
21. Did employee die?
YES
NO If so, give date of death____________________
(File amended report within 28 days if death subsequently occurs.)
22. Name and address of dependents (death cases only) _____________________________________________________________________________
___________________________________________________________________________________________________________________________
23. Insurance Carrier and Third Party Administrator____________________________________________________________________________________
Address ___________________________________________________________________________________________________________________
Street
City
State
ZIP
Phone
Policy Number_________________________________________________ Name of Agent________________________________________________
Claim Number____________________________________ Name of Claim Representative________________________________________________
24. Date of Report_____________________ Completed by_________________________________________ Title_______________________________
Questions or comments can be directed to the Kansas Division of Workers Compensation, Topeka, KS
–
Phone: 1-800-332-0353
- SUBMISSION DOES NOT CONSTITUTE ADMISSION OF LIABILITY -
K-WC 1101-A (Rev. 2-06)
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