1. FederalEmployer'sIdentificationNumber_________________________________________Dateofhire __________________

2. Nameofemployer____________________________________________________________Phone______________________

3. Mailingaddress___________________________________________________________________________________________________________ Street City State ZIPCode

4. Location,ifdifferentfrommailingaddress_______________________________________________________________________________________ Street City State ZIPCode

5. Natureofbusiness_________________________________ NAICSorS.I.C.Code___________Dept.ordivision___________________________

6. Nameofemployee_________________________________________________________________________________Age______Sex______ First Middle Last7. Homeaddress ___________________________________________________________________________________________________________ Street City State ZIPCode

Birth Employee's Home8. SSN_____________________ date________________ occupation________________________________ phone_________________________9. Dateofinjuryoroccupationaldisease__________________Timeofinjury_________ a.m. p.m. Datereportedtoemployer__________________Datedisabilitybegan__________________Grossaverageweeklywage$_________________

10. Placeofaccidentorlastexposure ____________________________________________________________________________________________ City County State

11. Wasaccidentorlastexposureonemployer'spremises?c YESc NO

12. Howdidaccidentoccur? ___________________________________________________________________________________________________

________________________________________________________________________________________________________________________

13. Whatwasemployeedoingwheninjured?______________________________________________________________________________________

________________________________________________________________________________________________________________________

14. Namesubstanceorobjectthatdirectlycausedinjury*____________________________________________________________________________ ________________________________________________________________________________________________________________________

15. Describeindetailnatureandextentofinjury,indicatepartofbodyinvolved*___________________________________________________________ ________________________________________________________________________________________________________________________

16. Wasworkeradmittedtohospital?c YESc NODate__________________Treatedbyemergencyroomonly?c YESc NO

Hospitalnameandaddress _________________________________________________________________________________________________

17. Nameandaddressofattendingphysicianorclinic _______________________________________________________________________________ ________________________________________________________________________________________________________________________

18. Hasemployeereturnedtoregularduty?c YESc NOLightduty?c YESc NODate_________________________

19. Iscompensationnowbeingpaid?c YESc NODatefirst/initialpayment____________________

20.Weeklycompensationrate$____________________Isfurthermedicalaidneeded?c YESc NOc UNKNOWN

21. Didemployeedie?c YESc NOIfYES,givedateofdeath___________________(Fileamendedreportwithin28daysifdeathsubsequentlyoccurs.)

22. Name(s)andaddress(es)ofdependents(deathcasesonly)________________________________________________________________________

________________________________________________________________________________________________________________________

23. Insurancecarrierandthirdpartyadministrator___________________________________________________________________________________ Address ________________________________________________________________________________Phone__________________________ StreetCityStateZIPCode Policynumber____________________________________________Nameofagent___________________________________________________

Claimnumber___________________________________ Nameofclaimrepresentative________________________________________________

24. Dateofreport_________________Completedby______________________________________ Title_____________________________________

OSHA Case or File Number______________________________

KANSASDEPARTMENTOFLABORwww.dol.ks.gov

ACCIDENT REPORT K-WC1101-A(Rev.1-12)

Page1of2

Thereisa$250penaltyforrepeatedfailuretofileaccidentreportswithin28daysofthedatetheemployerisinformedoftheaccident.Submission does not constitute admission of liability.

– SEE INSTRUCTIONS ON PAGE 2 –

Mail or fax ORIGINAL report to: DivisionofWorkersCompensation 401SWTopekaBlvd.,Suite2 Topeka,KS66603-3105 Fax:(785)296-4216

Direct questions or comments to: Toll-free(800)332-0353

FOROFFICE

USE

CAUSE

NATURE

SEVERITY

COUNTY

SOURCE

MEMBER

0-NOTIMELOST1-TIMELOST2-MEDICAL3-FATAL

InstructionsYoumustanswereveryquestion;failuretoanswerallquestionsmaycausethereporttobereturnedtotheemployer.Returnedaccidentreportsmaycauseadelayofbenefitstotheinjuredemployeesandcouldsubjecttheemployertofines.

Mailorfaxtheoriginalreportonly.IfnotcompletedusingthefillablePDFform,thereportmustbeprintedneatlyinblackinkortypewritten.Ifnotlegible,thereportwillbereturnedwhichwilldelaytimelyprocessing.

Theemployermustsendthisaccidentreporttoitsinsurancecarrier,thirdpartyadministratororpoolassociationasindicatedintheemployer'sinsurancecontract.The employer is responsible for submitting the original report to the Division of Workers Compensation within 28 days of the date the employer is informed of the accident.

*Instructions for Questions 14 and 1514:Nametheobjectorsubstancewhichdirectlyinjuredtheemployee.Example:machineorobjectemployee struckorstruckemployee;vapororpoisonemployeeinhaledorswallowed;chemicalsorradiationwhich irritatedemployee'sskin;ifhernia,theobjectemployeewasliftingorpulling;etc.

15:Beasspecificaspossibleindicatingallthatisknownabouttheinjury.Namethepartofbodyinjured.

Definition of an Incapacitating InjuryTheWorkers’CompensationActsetsforthastricttimeframeforfilingaccidentreportswiththedivision.ThecontrollingstatuteisK.S.A.44-557(a),whichreadsasfollows:

(a)itisherebymadethedutyofeveryemployertomakeorcausetobemadeareporttothedirectorofanyaccident,orclaimedorallegedaccident,toanyemployeewhichoccursinthecourseoftheemployee’semploymentandofwhichtheemployerortheemployer’ssupervisorhasknowledge,whichreportshallbemadeuponaformtobepreparedbythedirector,within28days,afterthereceiptofsuchknowledge,ifthepersonalinjurieswhicharesustainedbysuchaccidentsaresufficientwhollyorpartiallytoincapacitatethepersoninjuredfromlabororserviceformorethantheremainderoftheday,shiftorturnonwhichsuchinjuriesweresustained.

Accidentreportsarenotrequiredforeverywork-relatedinjury.Thestatuterequiresareporttobefiledwhentheworker'swholeorpartialincapacitycontinuesbeyondthe"day,turn,orshiftwhichsuchinjuriesaresustained"astheresultofaccident."Incapacity"isnotspecificallydefinedwithinthelaw,butthedivisionbelievesthattheLegislature'sintentwastoreferenceaworker'swholeorpartiallossoftheabilitytoperformhisorherordinaryjobtasks.Whenindoubt,keepinmindthelawcontainsnopenaltyforfilingareportthatultimatelyprovestobeunnecessary.There are penalties, however, for failing to file a report when one was required.Thepenaltiesincludefinesandlimitationsonthedefensestheemployermayassertifaclaimisfiled.

OSHA RecordkeepingTheemployermustcompleteanInjuryandIllnessIncidentReport,OSHAForm301,withinseven(7)daysoflearningthatawork-relatedinjuryorillnesshasoccurred.AccordingtoOSHA'srecordkeepingrule,youmustkeepForm301,oranequivalentsubstituteonfileforfive(5)years.

TolearnmoreaboutOSHA'srecordkeepingrequirementsanddownloadforms,visit:www.osha.gov/recordkeeping/RKforms.html

Page2of2KansasDepartmentofLaborEmployer's Accident ReportK-WC1101-A(Rev.1-12)