Official Form 122 Utah PDF Details

Do you reside in the state of Utah and are finding yourself overwhelmed with the amount of paperwork required for official forms? Look no further! In this blog post, we will go over exactly what you need to know about Form 122 Utah, who is eligible to use it, and how to complete and submit it. You'll be an expert on all things related to Form 122 by the time you've finished reading this article!

QuestionAnswer
Form NameOfficial Form 122 Utah
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other names34-a-30108, 34A-6-301, first report of injury utah, incl

Form Preview Example

FORM 122

EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS

 

(Filing this form is not an admission of liability for the claim.)

G E N E R A L

Employer (Name & Address Include Zip)

Industry Code

Employer FEIN

 

 

Carrier/Administrator Claim Number

OSHA Log Number

Report Purpose Code

 

 

 

Jurisdiction

Jurisdiction Claim Number

 

 

 

Insured Report Number

 

 

 

 

 

Employer’s Location Address (If Different)

 

Location Number

 

 

 

 

 

Phone Number

 

 

 

C A R R I E R

C

L

A

I

M S

A D M I N

CARRIER/CLAIMS ADMINISTRATOR

 

 

 

 

Carrier (Name, Address & Phone Number)

Policy Period __________

 

Claims Administrator (Name, Address & Phone Number)

 

To _________

 

 

 

 

 

 

 

 

 

Check If Appropriate

 

 

 

 

Self-Insurance

 

 

 

Carrier FEIN

Policy/Self-Insured Number

 

Administrator FEIN

 

 

 

 

 

Agent Name and Code Number

EEMPLOYEE/WAGE

M

Name (Last, First, Middle) Address (incl. Zip)

 

 

 

 

 

 

Date of Birth

 

 

Social Security Number

 

 

Date Hired

State of Hire

 

P

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sex

 

 

 

 

Marital Status

 

 

 

 

 

Occupation / Job Title

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

 

 

 

Unmarried/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

O

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

single/Divorced

Employment Status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Married

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

Claimant may need an interpreter:

Yes

No

 

 

 

 

 

 

Unknown

 

 

 

 

 

 

 

 

 

NCCI Class Code

 

E

Language _______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Separated

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone

 

 

 

 

 

 

 

 

Number of Dependents

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

W

Rate _______________

 

 

 

 

 

Day

 

 

 

Month

 

Number of Days Worked/Week

Full Pay For Day of Injury

 

 

 

Yes

 

 

 

No

A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Per:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

G

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

 

 

 

 

 

 

 

 

 

Week

 

 

 

Other

 

 

 

 

 

 

 

 

Did Salary Continue

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OCCURRENCE/TREATMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time Employee

 

 

AM

 

Date of Injury/Illness

 

Time of Occurrence

 

 

 

AM Last Work Date

 

Date Employer

 

 

 

Date Disability

 

 

Began Work

 

 

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_________________

 

 

Notified

 

 

 

 

 

 

 

 

Began

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

O

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

Department Or Location Where Accident or Illness Exposure Occurred

 

 

 

All Equipment, Materials, or Chemicals Employee Was Using When

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accident Or Illness Exposure Occurred

 

 

 

 

 

 

 

 

 

C

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specific Activity The Employee Was Engaged In When The Accident Or Illness

 

 

 

Work Process The Employee Was Engaged In When Accident Or Illness

R

Exposure Occurred

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Exposure Occurred

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cause Of Injury Code

 

How Injury or Illness / Abnormal Health Condition Occurred, Describe the Sequence of Events and Include Objects or Substances that Directly Injured The

 

 

 

EEmployee or Made The Employee Ill

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

Date Return(ed) to Work

 

If Fatal, Give Date of

 

Were Safeguards Or Safety Equipment Provided?

YES

NO

 

 

Death

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Were They Used?

YES

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician/Health Care Provider (Name & Address)

 

Hospital (Name & Address)

Initial Treatment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No Medical Treatment

 

 

 

 

 

 

 

 

 

 

 

Minor: By Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Minor: Clinic/Hospital

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Emergency Care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospitalized – 24 hrs

 

 

 

 

 

 

 

 

 

 

 

Future Major Medical/Lost Time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Anticipated

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OOTHER

TWitnesses (Name & Phone Number)

H

 

 

 

 

E

 

 

 

 

Date Administrator Notified

Date Prepared

Preparer’s Name & Title

Phone Number

 

R

 

 

 

 

 

 

 

 

 

OFFICIAL FORM 122 REVISED 2/09

STATE OF UTAH ● LABOR COMMISSION ● DIVISION OF INDUSTRIAL ACCIDENTS

160 East 300 South ● P O. Box 146610 ● Salt Lake City, UT 84114-6610 ● Telephone: (801) 530-6800

FAX: (801) 530-6804 ● Toll Free: (800) 530-5090 ● www.laborcommission.utah.gov

For your protection Utah Law requires notice that worker’s compensation fraud is a crime. Please see back of this form for the full fraud statement

FRAUD – “Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison.”

INSTRUCTIONS TO EMPLOYER

The Employer’s First Report of Injury or Illness must be submitted to the Labor Commission, Division of Industrial Accidents, per Sections §34A-2-407 and §34A-3-10B, Utah Code Annotated (U.C.A.). 1997. Each employer shall file the report within seven days after the occurrence, or the employee’s notification of the same, which results in medical treatment by a physician, loss of consciousness, loss of work, restriction of work, or transfer to another job. Each employer shall file a subsequent report with the commission of any previously reported injury; or occupational disease that later resulted in death. Also, for your information, Section §34A-6-301(3)(b)(ii) states that each employer shall, within 8 hours of occurrence, notify the Division of Occupational Safety and Health, at (801) 530-6901 or (800) 530-5090, of any; work related fatality; disabling, serious, or significant injury; or occupational disease incident. A serious injury includes; amputation, fractures of major bones (both simple and compound), and hospitalization for medical treatment.

*All information requested on this form is of vital importance. Please answer all items in detail in order to avoid additional correspondence or the return of this report for completion. Do not enter data in the shaded areas.

*The box titled “OSHA Log Number” must be filled in with the employer assigned Case Number from OSHA’s new 300 Injury Log. The Case Number needs to reflect the year of the injury – for example, your first injury in 2002 should reflect the first injury and the year 00/02 with the next injury being 00202, etc.

*Please provide WAGE information. This information is needed by the insurance company for paying the correct amount on a claim.

*The injury report on file with the Labor Commission, Division of Industrial Accidents, is private information and is only released to parties to the claim.

*Please make sure the EMPLOYER NAME is correct, as well as your FEIN # (Federal Tax ID Number). The employer’s name should be the same as reported to The Department of Workforce Services and as it appears on your WORKERS’ COMPENSATION insurance policy.

*The Labor Commission is to receive an original of this report, Worker’s Compensation Insurance Carrier gets a second copy, the employee gets a third copy, and the employer gets a fourth copy and should maintain a copy of this report.

*Failure to file this report with the Labor Commission or failure to provide the employee with a copy of the report, is a Class C misdemeanor and can also result in a citation and a civil penalty for each violation as per §34A-2-407(7), §34-a-30108(7), §34A-6-302, and §34A-6-307, U.C.A.

*If you dispute the validity of this claim you need to contact your insurance carrier, but you must still file the “Employer’s First Report of Injury or Illness” form with the Labor Commission.

*Reminder: Inform your injured employee of his/her rights and obligations (as outlined on the back of the employee’s copy) of Utah’s Workers’ Compensation Act.

For Additional Information please contact:

State of Utah – Labor Commission Division of Industrial Accidents 160 East 300 South, 3rd Floor

P O Box 146610

Salt Lake City, Utah 84114-6610 (801) 530-6800 (800) 530-5090

FRAUD – “Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison.”

EMPLOYEE INFORMATION

•INJURY/ILLNESS REPORT: A report of your injury/occupational illness must be made with your employer. If a report of injury is not filed with your employer or the Labor Commission, Division of Industrial Accidents, within 180 days of the date of your injury/illness, you may lose the right to ever file a claim for workers’ compensation benefits for that injury or illness.

•EMPLOYER’S PHYSICIAN: If your employer has a company physician or designated clinic for industrial accidents, you MUST see the company physician first, or you may not be eligible for workers’ compensation benefits. After you have been seen by your employer’s physician, you have the right to choose one treating physician.

•MEDICAL COOPERATION: You must cooperate with your employer or the insurance carrier in following prescribed medical treatment in order to return to work as quickly as possible.

•TRAVEL REIMBURSEMENT: You may be eligible for travel reimbursement to and from approved medical care. You will need to keep records. Contact your insurance carrier regarding travel expenses.

•REEMPLOYMENT ASSISTANCE: You may be eligible for reemployment assistance if you are unable to return to work due to an industrial injury. Contact your insurance carrier or the Labor Commission, Division of Industrial Accidents, for further information.

•MEDICAL EXPENSES: You are entitled to have all reasonable medical expenses paid that are a result of the injury or illness.

•COMPENSATION BENEFITS: You are entitled to 66-2/3 of your wages up to 100% of the state average weekly wage (as of the date of your injury) after 3 days from the date of your injury, if a physician states you are totally unable to work.

□If you have sustained a permanent impairment due to the industrial injury or disease, you are entitled to compensation based on the impairment rating as determined by a physician.

□If you are permanently totally disabled from working due to the industrial injury, you may need to apply at the Labor Commission, Division of Industrial Accidents, for a hearing to determine if benefits are due.

•ADDITIONAL ASSISTANCE: If you are unable to work due to an industrial injury and meet the program’s requirements, you may be eligible for other assistance. Agencies you may wish to contact:

□Department of Workforce Services for food stamps, cash assistance, medical assistance, or employment assistance.

□Social Security for total disability benefits.

•UNEMPLOYMENT BENEFITS: If you are able to work, but have been terminated from your job, you need to apply at the nearest Department of Workforce Services employment office within 90 calendar days after you are released from full-time work by your doctor.

Contact your insurance carrier if problems occur during your injury regarding payment of medical bills or compensation benefits. If you need to know who your employer’s insurance carrier is, you may ask your employer or contact the Labor Commission, Division of Industrial Accidents.

THIS IS AN IMPORTANT DOCUMENT TO MAINTAIN FOR YOUR RECORDS

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It is easy to finish the pdf with this practical guide! This is what you need to do:

1. It is recommended to complete the incl correctly, hence be mindful when filling out the parts that contain all these fields:

FEIN conclusion process outlined (stage 1)

2. Now that the previous part is complete, you're ready include the required particulars in W A G E, Claimant may need an interpreter, Female, Unknown, Number of Dependents, singleDivorced, Employment Status, Married, Separated, Unknown, NCCI Class Code, Rate, Per, Day, and Week so you're able to move on to the 3rd part.

FEIN completion process clarified (portion 2)

3. The next step is normally quite easy, Date Returned to Work, If Fatal Give Date of, Were Safeguards Or Safety, Death, Were They Used, YES, YES, PhysicianHealth Care Provider Name, Hospital Name Address, Initial Treatment, No Medical Treatment, Minor By Employer, Minor ClinicHospital, Emergency Care, and Hospitalized hrs - each one of these form fields has to be completed here.

Guidelines on how to fill in FEIN portion 3

4. It's time to fill in this fourth segment! In this case you will get all these If you have sustained a permanent, If you are permanently totally, ADDITIONAL ASSISTANCE If you are, requirements you may be eligible, Department of Workforce Services, UNEMPLOYMENT BENEFITS If you are, Contact your insurance carrier if, bills or compensation benefits If, and THIS IS AN IMPORTANT DOCUMENT TO form blanks to complete.

Find out how to fill out FEIN part 4

It is easy to make an error while filling in the If you have sustained a permanent, for that reason make sure that you look again prior to deciding to finalize the form.

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