Form Hr 112 PDF Details

Form HR 112, also known as the "Employer Report of Health Insurance Coverage" is a document that employers must file with the IRS every year. This report details the health insurance coverage that was offered to employees during the previous calendar year. Filing this form is mandatory for all employers, regardless of size or structure. The deadline for submitting Form HR 112 is March 1st each year. Questions about Form HR 112 can be directed to the IRS at 800-829-1040. Additional information about this form and other employer reporting requirements can be found in IRS Publication 15 (Circular E), Employer's Tax Guide.

QuestionAnswer
Form NameForm Hr 112
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesHR_112_Injury_G rant_Applicatio n_Form injury grant hr112 form

Form Preview Example

Injury Grant

Application Form – HR 112

This form is used to apply for a the payment of Injury Grant under Article 49/109 of the Local

Government (Superannuation) (Consolidation) Scheme 1998 in respect of an injury sustained while

performing official duties. Please complete form in Block Capitals/Tick appropriate boxes

Part 1.

Section 1 Personal Details (To be completed by the employee)

Name

PPS No

Personnel No

Grade/Occupation

Service

Address for HSE correspondence

Tel No:

Mobile No:

I understand that should my application be successful, that any period for which I am in receipt of an injury grant will not be included as service for pension benefit purposes.

Signature

Date

Section 2 - Accident Details (To be completed by the Line Manager)

Date of accident

Time of Accident (24 HR Clock)

Place where accident happened?

Details of Accident:

HR 112_V2 Apr 2010

Page 1 of 3

Revised 01/04/2010

What was the employee doing at the time of the Accident?

Nature of Injuries: (Attach a copy of medical certificate or death certificate in the case of a fatality)

Was the employee authorised to be at the place of the accident for the purpose of his/her work?

Yes

No

Date accident first reported to HSE?

To who was the accident reported?

Was an investigation of the accident carried out:

By whom was the accident investigated (attach copies of Incident Report Form, Occupational Health and other relevant reports, witnesses statements, etc)

Yes

No

Section 3 – Witnesses Details (To be completed by Line Manager)

Name:

Address

Tel No:

Name:

Address

Tel No:

Name:

Address

Tel No:

Grade

Mobile No:

Grade

Mobile No:

Grade

Mobile No:

Line Manager Name (print)

Job Title

Contact Tel. No:

Signature:

Date

HR 112_V2 Apr 2010

Page 2 of 3

Revised 01/04/2010

Part 2 To be completed by Senior Manager/General Manager

Under the terms of Article 49/109 of the Local Government (Superannuation) (Consolidation) Scheme 1998

I recommend that the payment of the injury grant is granted in this case

I refuse this application

Comments: (if application is refused, state reason)

Senior Manager Name:

Job Title

Signature

Date

Part 3 To be completed by Assistant Director of Human Resource

Under the terms of Article 49/109 of the Local Government (Superannuation) (Consolidation) Scheme 1998 be invoked in this case to provide for the payment of Injury Grant

I recommend this application

I refuse this application

Comments: (if application is refused, state reason)

Name:

Signature:

Assistant Director of HR

Date

HR 112_V2 Apr 2010

Page 3 of 3

Revised 01/04/2010