Free K-WC 1101-A for web only.indd - Kansas

EMPLOYER'S REPORT OF ACCIDENT
Division of Workers Compensation DIVISION OF WORKERS COMPENSATION
800 SW JACKSON STE 600 TOPEKA KS 66612-1227 Submit original report only

OSHA Case or File Number ______________________________

DO NOT WRITE IN THIS SPACE

There is a $250 penalty for repeated failure to file Accident Reports within 28 days of the employer's receipt of knowledge of the accident.
COUNTY

READ ATTACHED INSTRUCTIONS BEFORE COMPLETING THIS FORM.
1. 2. 3. 4. 5. 6. 7. Federal Employer's Identification Number_________________________________________ DateofHire:____________________________________

Name of Employer____________________________________________________________ Telephone Number (_________)__________________ Mailing Address__________________________________________________________________________________________________________
Street City State Zip Code CAUSE

Location, if different from mailing address________________________________________________________________________________________
Street City State Zip Code NATURE

Nature of Business___________________________
First

NAICS or S.I.C. Code_________________
Middle Last

Dept. or Division ________________________
SEVERITY O - NO TIME LOST 1 - TIME LOST 2 - MEDICAL 3 - FATAL SOURCE

Name of Employee ____________________________________________________________________________________ Age______ Sex______ Home Address _______________________________________________________________________________________________________________
Street City State Zip Code

8. 9.

Birth Employee's Home Phone Soc. Sec. #________________________ Date________________ Occupation_________________________ Number (_______)________________ Date of Injury or Occupational Disease___________________________________________________ Time of Injury_________________A.M./P.M. Date reported to employer__________________
City

Date Disability Began__________________
County

Gross Average Weekly Wage $_______________
State

10. Place of Accident or last exposure ______________________________________________________________________________________________
MEMBER

11. Was accident or last exposure on employer's premises?

YES

NO
DO NOT WRITE IN THIS SPACE

12. How did accident occur? ______________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ 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? 19. Is compensation now being paid? YES YES NO NO Light duty? YES NO Date________________________

Date first/initial payment_______________________________________________ YES NO UNKNOWN

20. Weekly compensation rate $_____________________________ Is further medical aid needed? 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 K-WC 1101-A (Rev. 2-06) ­ Phone: 1-800-332-0353

- SUBMISSION DOES NOT CONSTITUTE ADMISSION OF LIABILITY -

(not to be filed with the Division of Workers Compensation)
25. Case number from the Log __________________ (Transfer the case number from the Log after you record the case.) 26. Date of injury or illness _____________________ 27. Time employee began work _________________ A.M. / P.M. 28. Time of event _____________________________ A.M. / P.M. Check if time cannot be determined.

OSHA Case Information

29. What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment or material the employee was using. Be specific. Examples: "climbing a ladder while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-entry." ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 30. What happened? Tell us how the injury occurred. Examples: "When ladder slipped on wet floor, worker fell 20 feet"; "Worker was spraying with chlorine when gasket broke during replacement"; "Worker developed soreness in wrist over time." ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 31. What was the injury or illness? Tell us the part of the body that was affected and how it was affected. Be more specific than "hurt," "pain," or "sore." Examples: "strained back"; "chemical burn, hand"; "carpal tunnel syndrome." ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 32. What object or substance directly harmed the employee? Examples: "concrete floor"; "chlorine"; "radial arm saw". If this question does not apply to the incident, leave blank. ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 33. If the employee died, when did death occur? Date of death ______________________________________________

General Instructions
Please answer every question on the accident report. Failure to provide all answers may cause the accident report to be returned to the employer. Returned accident reports would most likely cause delays in benefits being paid to the injured employees and could subject the employer to fines. Submit the original report only. Reports must be typewritten, computer generated, or neatly printed in black ink. Please avoid faxing or sending copies of accident reports, as they are difficult for the Division to microfilm. The employer should send this accident report to its insurance carrier, third party administrator or pool association as indicated in the employer's insurance contract. The employer is responsible for submitting or causing the original report to be sent to the Division's office within 28 days of the date of the employer's receipt of knowledge of the accident. Submission of this Employer's Report of Accident does not constitute a written claim.

Definition of an Incapacitating Injury
The Workers' Compensation Act sets forth a strict time frame for filing of accident reports with the Division. The controlling statute is K.S.A. 44-557(a), which reads as follows: (a) it is hereby made the duty of every employer to make or cause to be made a report to the director of any accident, or claimed or alleged accident, to any employee which occurs in the course of the employee's employment and of which the employer or the employer's supervisor has knowledge, which report shall be made upon a form to be prepared by the director, within 28 days, after the receipt of such knowledge, if the personal injuries which are sustained by such accidents are sufficient wholly or partially to incapacitate the person injured from labor or service for more than the remainder of the day, shift or turn on which such injuries were sustained. Accident reports are not required for every work related injury. The statute requires a report to be filed when the worker's whole or partial incapacity continues beyond the "day, turn, or shift which such injuries are sustained" as the result of accident. "Incapacity" is not specifically defined within the law, but the Division believes that the Legislature's intent was to reference a worker's whole or partial loss of the ability to perform his or her ordinary job tasks. When in doubt, keep in mind the law contains no penalty for filing a report that ultimately proves to be unnecessary. There are penalties, however, for failing to file a report when one was required. Those penalties are fines and limitations on the defenses the employer may assert should a claim be filed.

Instructions for Specific Items
Item 14: Name the object or substance which directly injured the employee. Example: machine or object employee struck or struck employee; vapor or poison employee inhaled or swallowed; chemicals or radiation which irritated employee's skin; if hernia, the object employee was lifting or pulling; etc. Item 15: Please be as specific as possible indicating all that is known about the injury. Name part of body injured.