Indiana State Form 34401 is a requirement for all businesses operating in the state of Indiana. This form is used to report annual gross receipts and other business information to the Indiana Department of Revenue. Completing this form accurately and timely is essential to maintaining compliance with state tax laws. Below, we will provide a detailed overview of what information is required on Form 34401, and how to complete it correctly.
Below are some specifics about indiana state form 34401. This figure will provide details about the form's length, finalization time, and the blanks you can be needed to fill.
Question | Answer |
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Form Name | Indiana State Form 34401 |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | indiana workers compensation forms, indiana state form 34401, form 34401 electronic, state form34401 |
INDIANA WORKER'S COMPENSATION
FIRST REPORT OF EMPLOYEE INJURY, ILLNESS
State Form 34401 (R9 /
Please return completed form electronically by an approved EDI process.
FOR WORKER'S COMPENSATION BOARD USE ONL
Jurisdiction |
Jurisdiction claim number |
Process date |
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PLEASE TYPE OR PRINT IN INK
NOTE: Your Social Security Number is being requested by this state agency in order to pursue its statutory responsibilities. Disclosure is voluntary and you will not be penalized for refusal.
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EMPLOYEE INFORMATION |
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Social Security Number |
Date of Birth |
Sex |
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Occupation / Job Title |
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NCCI class code |
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MALE |
FEMALE |
UNKNOWN |
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N/A |
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Name (last, first, middle) |
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Marital status |
Date hired |
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State of hire |
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Employee status |
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UNMARRIED |
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N/A |
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N/A |
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MARRIED |
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Address (number and street, city, state, ZIP code) |
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Hrs / Day |
Days / Wk |
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Avg Wg / Wk |
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Paid Day of Injury |
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SEPARATED |
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Salary Continued |
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UNKNOWN |
Wage |
Per |
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Telephone number (include area code) |
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Number of dependents |
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Hour |
Day |
Week |
Month |
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N/A |
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Year |
Other |
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EMPLOYER INFORMATION
Name of employer
Employer ID# |
N/A |
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SIC code N/A |
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Insured report number N/A |
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Location number |
N/A |
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Employer's location address (if different) |
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N/A |
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Telephone number N/A |
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Carrier / Administration claim number |
N/A |
Report purpose code |
N/A |
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00 |
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Actual location of accident / exposure (if not on employer's premises)
CARRIER / CLAIMS ADMINISTRATOR INFORMATION
Name of claims administrator |
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Carrier federal ID number |
Check if appropriate |
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N/A |
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N/A |
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N/A |
SELF INSURANCE |
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Address of claims administrator(number and street, city, state, ZIP code) N/A |
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Policy / |
N/A |
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Insurance Carrier N/A |
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Third PArty Admin. N/A |
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Policy period |
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Telephone number |
N/A |
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N/A |
TO N/A |
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FROM |
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Name of agent |
N/A |
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Code number |
N/A |
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OCCURRENCE / TREATMENT INFORMATION |
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Date of Inj. / Exp. |
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Time of occurrence |
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Date employer notified |
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Type of injury / exposure |
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Type code |
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AM |
PM |
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N/A |
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Last work date |
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Time workday began |
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Date disability began |
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Part of body |
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Part code |
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N/A |
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RTW date |
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Date of death |
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Injury / Exposure occurred |
YES |
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Name of contact N/A |
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Telephone number |
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N/A |
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on employer's premises? |
NO |
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Department or location where accident / exposure occurred |
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All equipment, materials, or chemicals |
N/A |
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NA |
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Specific activity engaged in during accident / exposure |
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Work process employee engaged in during accident / exposure |
N/A |
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NA |
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How injury / exposure occurred. Describe the sequence of events and include any relevant objects or substances.
Cause of injury code N/A
Name of physician / health care provider
Name of witness |
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Telephone number |
Date administrator notified |
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Date prepared |
Name of preparer |
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Title |
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Telephone number |
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INITIAL TREATMENT
No Medical Treatment
Minor: By Employer
Minor: Clinic / Hospital
Emergency Care
Hospitalized > 24 Hours
Future Major Medical / Lost
Time Anticipated
An employer's failure to report an occupational injury or illness may result in a $50 fine (IC