K Wc 1101 A Form PDF Details

Are you looking for an efficient way to complete your K WC 1101 form? Are you unsure of where to begin and what information is needed? If so, you've come to the right place! This comprehensive blog post will provide a step-by-step guide on how to successfully fill out your K WC 1101 form. Keep reading for helpful tips about all the essential details that need completing such as what documents are required, how to input data accurately and thoroughly, as well as advice from experienced practitioners who have submitted their own forms. Let's get started.

QuestionAnswer
Form NameK Wc 1101 A Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesk wc 1101 a rev 10 13, fillable k wc 1101 a, kansas dept of labor accident report, kansas employers report of accident form

Form Preview Example

KANSAS DEPARTMENT OF LABOR

www.dol.ks.gov

ACCIDENT REPORT

K-WC 1101-A (Rev. 1-12)

– SEE INSTRUCTIONS ON PAGE 2 –

There is a $250 penalty for repeated failure to ile accident reports within 28 days of the date the employer is informed of the accident. Submission does not constitute admission of liability.

Page 1 of 2

Mail or fax ORIGINAL report to: Division of Workers Compensation 401 SW Topeka Blvd., Suite 2 Topeka, KS 66603-3105

Fax: (785) 296-4216

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

OSHA Case or File Number ______________________________

1. Federal Employer's Identiication Number_________________________________________ Date of hire __________________

2.Name of employer____________________________________________________________ Phone ______________________

3.Mailing address___________________________________________________________________________________________________________

Street

City

State

ZIP Code

4.Location, if different from mailing address_______________________________________________________________________________________

Street

City

State

ZIP Code

5.Nature of business_________________________________ NAICS or S.I.C. Code___________ Dept. or division ___________________________

6. Name of employee _________________________________________________________________________________

Age______ Sex______

First

Middle

Last

 

7.Home address ___________________________________________________________________________________________________________

Street

 

City

State

ZIP Code

Birth

Employee's

 

Home

 

8.SSN_____________________ date________________ occupation________________________________ phone _________________________

9.

Date of injury or occupational disease__________________

Time of injury_________ a.m.

p.m.

 

 

 

Date reported to employer__________________ Date disability began__________________ Gross average weekly wage $_________________

10.

Place of accident or last exposure ____________________________________________________________________________________________

 

City

 

 

County

 

 

State

11.

Was accident or last exposure on employer's premises?

c YES

 

 

 

 

 

c

NO

 

 

 

12.How did accident occur? ___________________________________________________________________________________________________

________________________________________________________________________________________________________________________

13.What was employee doing when injured? ______________________________________________________________________________________

________________________________________________________________________________________________________________________

14.Name substance or object that directly caused injury* ____________________________________________________________________________

________________________________________________________________________________________________________________________

15.Describe in detail nature and extent of injury, indicate part of body involved*___________________________________________________________

________________________________________________________________________________________________________________________

16. Was worker admitted to hospital? c YES c NO Date__________________

Treated by emergency room only? c YES c NO

Hospital name and address _________________________________________________________________________________________________

17.Name and address of attending physician or clinic _______________________________________________________________________________

________________________________________________________________________________________________________________________

18.

Has employee returned to regular duty?

c YES

c NO

Light duty? c YES

c NO

Date_________________________

19.

Is compensation now being paid? c YES

c NO

Date irst/initial payment____________________

20.

Weekly compensation rate $____________________

 

Is further medical aid needed?

c YES

c NO c UNKNOWN

21.

Did employee die? c YES c NO

If YES, give date of death___________________ (File amended report within 28 days if death subsequently occurs.)

22.Name(s) and address(es) of dependents (death cases only) ________________________________________________________________________

________________________________________________________________________________________________________________________

23.Insurance carrier and third party administrator ___________________________________________________________________________________

Address ________________________________________________________________________________ Phone __________________________

Street

City

State

ZIP Code

Policy number____________________________________________

Name of agent___________________________________________________

Claim number___________________________________

Name of claim representative________________________________________________

24. Date of report_________________ Completed by______________________________________ Title_____________________________________

FOR

OFFICE

USE

COUNTY

CAUSE

NATURE

SEVERITY

0 - NO TIME LOST

1 - TIME LOST

2 - MEDICAL

3 - FATAL

SOURCE

MEMBER

Kansas Department of Labor

Page 2 of 2

Employer's Accident Report

K-WC 1101-A (Rev. 1-12)

Instructions

You must answer every question; failure to answer all questions may cause the report to be returned to the employer. Returned accident reports may cause a delay of beneits to the injured employees and could subject the employer to ines.

Mail or fax the original report only. If not completed using the illable PDF form, the report must be printed neatly in black ink or typewritten. If not legible, the report will be returned which will delay timely processing.

The employer must send this accident report to its insurance carrier, third party administrator or pool association as indicated in the employer's insurance contract. 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 15

14:Name the object or substance which directly injured the employee. Example: machine or object employee struck or struck employee; vapor or poison employee inhaled or swallowed; chemicals or radiation which irritated employee's skin; if hernia, the object employee was lifting or pulling; etc.

15:Be as speciic as possible indicating all that is known about the injury. Name the part of body injured.

Deinition of an Incapacitating Injury

The Workers’ Compensation Act sets forth a strict time frame for iling accident reports with the division. The controlling statute is K.S.A. 44-557(a), which reads as follows:

(a)it is hereby made the duty of every employer to make or cause to be made a report to the director of any accident, or claimed or alleged accident, to any employee which occurs in the course of the employee’s employment and of which the employer or the employer’s supervisor has knowledge, which report shall be made upon a form to be prepared by the director, within 28 days, after the receipt of such knowledge, if the personal injuries which are sustained by such accidents are suficient wholly or partially to incapacitate the person injured from labor or service for more than the remainder of the day, shift or turn on which such injuries were sustained.

Accident reports are not required for every work-related injury. The statute requires a report to be iled when the worker's whole or partial incapacity continues beyond the "day, turn, or shift which such injuries are sustained" as the result of accident. "Incapacity" is not speciically deined within the law, but the division believes that the Legislature's intent was to reference a worker's whole or partial loss of the ability to perform his or her ordinary job tasks. When in doubt, keep in mind the law contains no penalty for iling a report that ultimately proves to be unnecessary. There are penalties, however, for failing to ile a report when one was required. The penalties include ines and limitations on the defenses the employer may assert if a claim is iled.

OSHA Recordkeeping

The employer must complete an Injury and Illness Incident Report, OSHA Form 301, within seven (7) days of learning that a work-related injury or illness has occurred. According to OSHA's recordkeeping rule, you must keep Form 301, or an equivalent substitute on ile for ive (5) years.

To learn more about OSHA's recordkeeping requirements and download forms, visit:

www.osha.gov/recordkeeping/RKforms.html

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