Get the free first report of injury or illness - Utah Labor Commission - Utah.gov - laborcommissi...
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FIRST REPORT OF INJURY OR ILLNESSForm 122CRevised 2/2019TO BE COMPLETED BY INSURANCE CARRIER OR REINSURED EMPLOYER
NOTICE TO INJURED WORKER: This form is to notify you, the injured worker, the insurance
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How to fill out first report of injury
How to fill out first report of injury
01
To fill out the first report of injury, follow these steps:
02
Gather all necessary information about the injured person, such as their full name, contact details, and job title.
03
Identify the date and time of the injury. Record the exact location where the injury occurred.
04
Describe the details of the injury and how it happened. Include information about any witnesses present during the incident.
05
Provide a detailed account of the injuries sustained, including any visible wounds or physical symptoms.
06
If medical treatment was sought, document the name of the healthcare provider or facility where the injured person received treatment.
07
Include any supplemental documents related to the incident, such as photos, videos, or incident reports.
08
Review the completed report for accuracy and make any necessary adjustments.
09
Sign and date the report, indicating that the information provided is correct and complete.
10
Submit the report to the designated authority or department responsible for handling injury reports.
11
Keep a copy of the report for future reference and record-keeping purposes.
Who needs first report of injury?
01
The first report of injury is needed by employers, employees, and insurance companies.
02
Employers require this report to document and investigate workplace injuries for regulatory compliance and to implement necessary measures to prevent future incidents.
03
Employees need the report to report the details of their injury accurately, ensuring they receive proper medical treatment and workers' compensation benefits if applicable.
04
Insurance companies rely on the first report of injury to process claims and determine the eligibility of compensation for medical expenses and lost wages.
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What is first report of injury?
The first report of injury is a documentation of an employee's work-related injury or illness.
Who is required to file first report of injury?
Employers are required to file the first report of injury when an employee experiences a work-related injury or illness.
How to fill out first report of injury?
The first report of injury can typically be filled out online through a designated reporting system provided by the employer or workers' compensation agency.
What is the purpose of first report of injury?
The purpose of the first report of injury is to document and report work-related injuries or illnesses to ensure that the employee receives appropriate medical treatment and workers' compensation benefits.
What information must be reported on first report of injury?
The first report of injury typically includes information such as the employee's name, date of injury, description of injury, witnesses, and any medical treatment received.
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