34401 Details

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.

QuestionAnswer
Form NameIndiana State Form 34401
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesindiana workers compensation forms, indiana state form 34401, form 34401 electronic, state form34401

Form Preview Example

INDIANA WORKER'S COMPENSATION

FIRST REPORT OF EMPLOYEE INJURY, ILLNESS

State Form 34401 (R9 / 3-01)

Please return completed form electronically by an approved EDI process.

FOR WORKER'S COMPENSATION BOARD USE ONL

Jurisdiction

Jurisdiction claim number

Process date

 

 

 

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.

 

 

 

EMPLOYEE INFORMATION

 

 

 

 

 

 

 

 

 

Social Security Number

Date of Birth

Sex

 

 

 

Occupation / Job Title

 

 

 

 

NCCI class code

 

 

MALE

FEMALE

UNKNOWN

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (last, first, middle)

 

 

 

Marital status

Date hired

 

State of hire

 

 

Employee status

 

 

 

 

 

UNMARRIED

 

 

N/A

 

 

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MARRIED

 

 

 

 

 

 

 

 

Address (number and street, city, state, ZIP code)

 

 

 

Hrs / Day

Days / Wk

 

Avg Wg / Wk

 

 

 

Paid Day of Injury

 

 

 

 

 

SEPARATED

 

 

 

 

 

 

 

 

Salary Continued

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UNKNOWN

Wage

Per

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone number (include area code)

 

 

 

Number of dependents

 

 

Hour

Day

Week

Month

 

 

 

 

 

N/A

 

 

Year

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER INFORMATION

Name of employer

Employer ID#

N/A

 

SIC code N/A

 

Insured report number N/A

Location number

N/A

 

Employer's location address (if different)

 

 

 

 

 

N/A

 

Telephone number N/A

 

 

 

 

 

 

 

 

Carrier / Administration claim number

N/A

Report purpose code

N/A

 

 

 

 

00

 

 

 

 

 

 

 

 

Actual location of accident / exposure (if not on employer's premises)

CARRIER / CLAIMS ADMINISTRATOR INFORMATION

Name of claims administrator

 

 

 

Carrier federal ID number

Check if appropriate

 

 

 

 

N/A

 

 

 

N/A

 

N/A

SELF INSURANCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address of claims administrator(number and street, city, state, ZIP code) N/A

 

 

 

 

Policy / Self-insured number

N/A

Insurance Carrier N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Third PArty Admin. N/A

 

 

 

 

 

 

 

 

 

 

Policy period

 

 

Telephone number

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

TO N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of agent

N/A

 

 

Code number

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OCCURRENCE / TREATMENT INFORMATION

 

 

 

 

 

Date of Inj. / Exp.

 

Time of occurrence

 

Date employer notified

 

 

Type of injury / exposure

 

 

 

 

Type code

 

 

AM

PM

 

 

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last work date

 

Time workday began

 

Date disability began

 

 

Part of body

 

 

 

 

Part code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RTW date

 

Date of death

 

Injury / Exposure occurred

YES

 

Name of contact N/A

 

Telephone number

 

 

 

 

 

 

N/A

 

 

 

 

on employer's premises?

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Department or location where accident / exposure occurred

 

 

All equipment, materials, or chemicals

N/A

 

 

 

 

 

 

 

 

 

 

NA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specific activity engaged in during accident / exposure

 

 

 

 

 

Work process employee engaged in during accident / exposure

N/A

 

 

 

 

 

 

 

 

NA

 

 

 

 

 

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

 

Telephone number

Date administrator notified

 

 

 

 

 

 

Date prepared

Name of preparer

 

Title

 

Telephone number

 

 

 

 

 

 

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 22-3-4-13)

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