Fillable Form Ica 04-0101 - Employer'S Report Of Industrial Injury

EMPLOYER'S REPORT

INDUSTRIAL COMMISSION OF ARIZONA

FOR CARRIER USE ONLY

OF INDUSTRIAL INJURY

P.O. BOX 19070

____________________________________

PHOENIX, ARIZONA 85005-9070

COMPLETE AND MAIL THIS REPORT WITHIN 10

FOR OSHA PURPOSES ONLY

DAYS FROM NOTICE OF ACCIDENT. FATALITIES

MUST BE REPORTED WITHIN 24 HOURS.

MAIL TO: (CARRIER NAME & ADDRESS)

OSHA Case #: _______________________________________

Employer must, on this form, notify his insurance carrier of

every injury or disease suffered by an employee, fatal or

RECORDABLE INJURY

______________________

otherwise, which is claimed to arise out of or in the course of

employment. ARIZONA REVISED STATUTES 23-908 &

NON-RECORDABLE INJURY

______________________

23-1061

EMPLOYEE

LAST NAME

FIRST

M.I.

SOCIAL SECURITY NUMBER*

BIRTH DATE

HOME ADDRESS (NUMBER & STREET)

CITY

STATE

ZIP CODE

TELEPHONE

MARITAL STATUS:

SEX

MALE

FEMALE

SINGLE

MARRIED

DIVORCED

WIDOWED

EMPLOYER

EMPLOYER'S NAME

POLICY NUMBER

10. NATURE OF BUSINESS (MANUFACTURING, ETC.)

11. OFFICE ADDRESS (NUMBER & STREET)

CITY

STATE

ZIP CODE

12. TELEPHONE

13. DATE OF INJURY OR ILLNESS

14. TIME OF EVENT

15. TIME EMPLOYEE BEGAN WORK

16. DATE EMPLOYER NOTIFIED OF INJURY

ACCIDENT

A.M.

P.M.

A.M.

P.M.

17. LAST DAY OF WORK AFTER INJURY

18. DATE OF RETURN TO WORK

19. EMPLOYEE'S OCCUPATION (JOB TITLE) WHEN INJURED

20. CLASS CODE ON PAYROLL REPORT

21. EMPLOYEE'S ASSIGNED DEPARTMENT

22. DEPARTMENT NUMBER

23. DID INJURY OCCUR ON EMPLOYER PREMISES?

YES

24. ADDRESS OR LOCATION OF ACCIDENT

CITY

COUNTY

STATE

ZIP CODE

Examples: "strained back"; "chemical burn, hand";

25. 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."

"carpal tunnel syndrome."

26. PART OF BODY INJURED

27. FATAL

28. IF THE EMPLOYEE DIED, WHEN DID THE DEATH OCCUR? DATE OF DEATH

YES

29. WAS EMPLOYEE TREATED IN AN EMERGENCY

NAME OF PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL

ADDRESS (STREET, CITY, STATE & ZIP CODE)

ROOM?

YES

30. WAS EMPLOYEE HOSPITALIZED OVERNIGHT

IF HOSPITALIZED, HOSPITAL NAME

ADDRESS (STREET, CITY, STATE & ZIP CODE)

AS AN IN-PATIENT?

YES

31. IF VALIDITY OF CLAIM IS DOUBTED, STATE REASON

CAUSE OF

Examples:

32. WHAT HAPPENED? Tell us how the injury occurred.

"When ladder slipped on wet floor, worker fell 20 feet"; "Worker was sprayed with chlorine when gasket broke during replacement";

"Worker developed soreness in wrist over time."

ACCIDENT

Examples:

If this question does not apply to the incident, leave it blank.

33. WHAT OBJECT OR SUBSTANCE DIRECTLY HARMED THE EMPLOYEE?

"concrete floor"; "chlorine"; "radial arm saw."

Examples:

34. WHAT WAS EMPLOYEE DOING JUST BEFORE THE INCIDENT OCCURRED? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific.

"climbing a ladder while

carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-entry."

35. IF ANOTHER PERSON NOT IN COMPANY EMPLOY CAUSED ACCIDENT, GIVE NAME AND ADDRESS

36. WAS WORKER IN YOUR EMPLOY

37. HOURS PER DAY EMPLOYEE WORKED

38. WAS EMPLOYEE ON OVERTIME

39. NUMBER OF DAYS PER WEEK

EMPLOYEE'S

WHEN INJURED?

USUALLY WORKED

WAGE DATA

YES

FROM

A.M.

P.M.

THRU

A.M.

P.M.

EMPLOYEE

COMPANY

IF WORK LOSS IS EXPECTED TO EXCEED SEVEN

40. DATE OF LAST HIRE

41. WAS WORKER PAID FOR DAY OF INJURY?

42. WAS EMPLOYEE HIRED FOR PERMANENT

IMPORTANT

CALENDAR DAYS, COMPLETE ITEMS 40 THRU 47

EMPLOYMENT?

YES

IF YES,

YES

43. NUMBER OF MONTHS EMPLOYMENT

44. GIVE EMPLOYEE'S WAGE STATUS AS APPLICABLE

45. IS EMPLOYEE FURNISHED

VALUE

AVAILABLE DURING THE YEAR

HOUR

DAY

WEEK

MONTH

per

LODGING

BOARD

BOTH

46. ACTUAL GROSS EARNINGS OF EMPLOYEE FOR THE 30 CALENDAR DAYS PRECEDING INJURY

47. DOES EMPLOYEE CLAIM DEPENDENTS?

YES

(EXAMPLE: IF INJURED APRIL 8, GIVE EARNINGS FROM MARCH 9 THRU APRIL 7)

IF EMPLOYEE IS PAID OTHER THAN FIXED WEEKLY

48. IF EMPLOYEE EARNS EXTRA PAY FOR OVERTIME, WHAT IS

49. NUMBER OF HOURS OVERTIME CONSIDERED NORMAL PER

IMPORTANT

OR MONTHLY SALARY, COMPLETE ITEMS 48 THRU 55

BASIS OF PAYMENT?

WEEK

PER HOUR

GROSS WAGES OF EMPLOYEE DURING 12 MONTHS PRECEEDING INJURY

51. IF EMPLOYEE WORKED LESS THAN 12 MONTHS, SHOW GROSS WAGES FROM DATE OF HIRE

THROUGH DAY PRIOR TO INJURY

FROM

THRU

FROM

THRU

52. DATE OF LAST WAGE INCREASE IF

53. WAGE BEFORE INCREASE

54. WAGE AFTER INCREASE

55. GROSS EARNINGS FROM DATE OF INCREASE THRU DAY PRIOR TO INJURY

WITHIN 12 MONTHS PRIOR TO INJURY

DATE

AUTHORIZED SIGNATURE

TITLE

AUTHORIZED

SIGNATURE

NOTE TO EMPLOYER:

Mail one copy to the Industrial Commission within 10 days.

Mail one copy to your insurance carrier within 10 days.

Keep one copy, for not less than five (5) years, as your supplementary record of

injuries required by the Federal Occupational Safety and Health Act of 1970.

* The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted by Section 7(a)(2)(B) of the Federal Privacy

Act of 1974, because the Commission's forms, prescribed under the Commission's rules in existence prior to January 1, 1975, required disclosure of the social security number. The number is used as a means of identifying all the

various records in the Claims Division or Special Fund pertaining to an individual. The use of social security numbers is made necessary because of the large number of persons who have similar names and birth dates, and whose

identities can only be distinguished by the social security number.

THIS FORM APPROVED BY THE INDUSTRIAL COMMISSION OF ARIZONA FOR CARRIER USE

Form ICA 04-0101 (Rev. 7/01)

WC 8418e (7-01)

UNIFORM INFORMATION SERVICES, INC.