Fillable First Report Of Injury Kentucky Details

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The listing holds specifics of the form ia 1. It'll give you the approximated time you'll need to fill out the form and some further details.

QuestionAnswer
Form NameForm Ia 1
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesKEMI, kentucky first report of injury, FEIN, fillable first report of injury kentucky

Form Preview Example

IA-1

 

 

 

 

 

WORKERS COMPENSATION - FIRST REPORT OF INJURY OR ILLNESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer (Name & Address Including Zip)

 

 

 

 

 

Carrier/Administration Claim Number

 

 

 

 

 

Report Purpose Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Jurisdiction

Jurisdiction Claim Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insured Report Number KY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer’s Location Address (if different)

Location #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIC Code

 

 

Employer FEIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Carrier/Claims Administrator

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Kentucky Employers’ Mutual Ins.

 

 

 

 

 

Policy Period

Claims Administrator (Name, Address, Phone No)

 

Lexington Financial Center

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

250 W. Main Street, Suite 900

 

 

 

 

 

 

 

To

 

 

 

 

 

 

 

 

 

 

 

 

 

Lexington, KY 40507

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone: (859) 425-7800

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax: (859) 425-7822

 

 

 

 

 

 

 

 

 

 

Check if Appropriate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self Insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

Carrier FEIN

 

 

 

 

 

Policy/Self-Insured Number

 

 

 

Administrator FEIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agent Name & Code Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (Last, First, Middle)

 

 

 

 

 

 

 

Date of Birth

Social Security No.

Date Hired

 

 

 

State of Hire

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address (include ZIP)

 

 

 

 

 

 

 

Sex

Marital Status

Occupation/Job Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M – Male

 

 

U - Unmarried

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single/Divorced

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F - Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M - Married

Employment Status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U - Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S - Separated

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone

 

 

 

 

 

 

 

 

 

# of Dependents

 

 

K - Unknown

NCCI Class Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rate

 

 

 

 

Day

 

Month

# Days Worked/Week

 

Full Pay for Day of Injury?

Yes

No

 

 

 

 

Per

 

 

 

 

 

 

 

 

 

Did Salary Continue?

 

 

 

Yes

No

 

 

 

 

 

 

Week

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Occurrence/Treatment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time Employee

AM

 

Date of Injury/Illness

 

 

Time of Occurrence

AM

 

Last Work Date

Date Employer Notified

Date Disability Began

 

 

Began Work

PM

 

 

 

 

 

 

 

 

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Name/Phone Number

 

 

 

 

 

Type of Injury/Illness

 

 

Part of Body Affected

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did Injury/Illness exposure occur on employer’s premises?

 

Type of Injury/Illness Code

Part of Body Affected Code

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Department or location where accident or illness exposure occurred

All equipment, materials, or chemicals employee was using when accident or illness exposure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

occurred

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specify activity the employee was engaged in when the accident or illness

Work process the employee was engaged in when accident or illness exposure occurred

 

exposure occurred

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How injury or illness/abnormal health condition occurred. Describe the sequence of events and include any objects or substances that

Cause of Injury Code

 

 

directly injured the employee or made the employee ill

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Returned to Work

 

If Fatal, Give Date of Death

 

 

 

Were Safeguards or Safety Equipment Provided?

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Were they Used?

 

 

 

 

 

 

 

Yes

No

 

 

Physician/Health Care Provider (Name & Address)

 

 

 

 

Hospital (Name & Address)

 

 

 

 

 

 

Initial Treatment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

0 No Medical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 Minor by Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

Minor Clinic/Hosp

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3 Emergency Care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

Hospitalized>24 Hrs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

Future Major Medical/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lost Time Anticipated

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Witnesses (Name & Phone #)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Admin/Carrier

 

 

Date Prepared

 

Preparer’s Name & Title

 

 

 

 

 

 

 

Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notified

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FORM IA-1

 

 

 

 

 

SEE BACK FOR IMPORTANT INFORMATION & SIGNATURE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

“Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance

containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.”

REPRINTED WITH PERMISSION OF THE IAIABC (AS MODIFIED BY AND FOR KEMI)

EMPLOYER’S INSTRUCTIONS

DO NOT ENTER DATA IN SHADED FIELDS

DATES:

Enter all dates in MM/DD/YY.

SIC CODE:

This is the code that represents the nature of the employer’s business that is contained in the Standard Industrial Classification Manual published by the Federal Office of Management and Budget.

CARRIER:

The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer or the claimant.

CLAIMS ADMINISTRATOR:

Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administering the claim.

AGENT NAME & CODE NUMBER:

Enter the name of your insurance agent and his/her code number if known. This information can be found on your insurance policy.

OCCUPATION/JOB TITLE:

This is the primary occupation of the claimant at the time of the accident or exposure.

EMPLOYMENT STATUS:

Indicate the employee’s work status. The valid choices are: Full-Time, Not Employed, Disabled, Unknown, Apprenticeship Part-Time, Seasonal, Part-Time, On Strike, Retired, Apprenticeship Full-Time, Volunteer, and Piece Worker.

DATE DISABILITY BEGAN:

The first day on which the claimant originally lost time from work due to the occupational injury or disease or as otherwise designated by the statute.

CONTACT NAME/PHONE NUMBER:

Enter the name of the individual at the employer’s premises to be contacted for additional information.

TYPE OF INJURY/ILLNESS:

Briefly describe the nature of the injury or illness, (e.g. Lacerations to the forearm).

PART OF BODY AFFECTED:

Indicate the part of body affected by the injury/illness, (e.g. Right forearm, lower back).

DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED:

(e.g. Maintenance Department or Client’s office at 452 Monroe St., Washington, DC 26210) If the accident or illness exposure did not occur on the employer’s premises, enter the address or location. Be specific.

ALL EQUIPMENT, MATERIAL OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSRE OCCURRED:

(e.g., Acetylene cutting torch, metal plate)

List all equipment, materials and/or chemicals the employee was using, applying, handling or operating when the injury or illness occurred. Be specific, for example: decorator’s scaffolding, electric sander, paintbrush, and paint.

Enter “NA” for not applicable if no equipment, materials or chemicals were being used. NOTE: The items listed do not have to be directly involved in the employee’s injury or illness.

SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED:

(e.g., Cutting metal plate for flooring)

Describe the specific activity the employee was engaged in when the accident or illness exposure occurred, such as sanding ceiling woodwork in preparation of painting.

WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED:

Describe the work process the employee was engaged in when the accident or illness exposure occurred, such as building maintenance. Enter “NA” for not applicable if employee was not engaged in a work process (e.g., walking along a hallway).

HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL:

(Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against the hot metal.)

Describe how the injury or illness/abnormal health condition occurred. Include the sequence of events and name any objects or substance that directly injured the employee or made the employee ill. For example: Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The worker’s right wrist was broken in the fall.

DATE RETURN(ED) TO WORK:

Enter the date following the most recent disability period on which the employee returned to work.

“Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.”

Employee Signature:

 

DATE:

 

REPRINTED WITH PERMISSION OF THE IAIABC (AS MODIFIED BY AND FOR KEMI)

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