Form 122E EMPLOYER222S FIRST REPORT OF INJURY OR ILLNESS Revised 2/2019 160 East 300 South 3rd Floor P.O. Box 146610 Salt Lake City, Utah 84114-6610 Office: (801)-530-6800 Fax: (801)-530-6804 Toll Free: (800)-530-5090 www.laborcommission.utah.gov TO BE COMPLETED BY EMPLOYER WITH ORIGINAL SENT TO INSURANCE CARRIER AND COPY SENT TO INJURED WORKER INJURED WORKER INFOR MATION: Name: P hone: Address: City : State : Zip : Social Security Number: Date of Birth: Marital Status: Sex: Male Female Unknown Occupation / Job Title: Date Hired: Employment Status: Number of Dependents: Wage: Wage Period: Daily Weekly Monthly Full Pay for Day of Injury: Yes No Number of Days Worked per Week: EMPLOYER INFORMATION: Business Name: Phone: Employer Contact: Phone : Mailing Address: City: State: Zip: Employment Address : City: State: Zip: Employer FEIN: INSURANCE INFORMATION: Carrier: Phone: Carrier Address: City: State: Zip: Policy / Self - Insured Number: Policy Period: OCCURRE NCE /TREATMENT : Date of Injury / Disease: Time of Injury : Date Employer Notified: Nature: Body Part: Cause: Last Day Worked: Date Disability Began: Date Returned to Work: Fatality: Yes No Date of Death : Date Administrator Notified: Address of Occurrence: City: State: Zip: Premises: Employer222s Other Description: Accident Description: Provider Injured Worker Received Care From: Provider Address : C ity: State: Zip: Treating Physician: Phone: Initial T reatment: No Medical Treatment Minor: By Employer Minor: Clinic/Hospital Emergency Care Hospitalized - 24 Hours Future Major Medical/Lost Time Anticipated Witnesses: Yes No If yes list their names and phone number : For your protection, it is required by Utah Law to give notice that workers222 compensation fraud is a crime. S ee next page for full fraud statement. American LegalNet, Inc. www.FormsWorkFlow.com Form 122E EMPLOYER222S FIRST REPORT OF INJURY OR ILLNESS Revised 2/2019 160 East 300 South 3rd Floor P.O. Box 146610 Salt Lake City, Utah 84114-6610 Office: (801)-530-6800 Fax: (801)-530-6804 Toll Free: (800)-530-5090 www.laborcommission.utah.gov INST R UCTIONS TO THE EMPLOYER PLEASE NOTE: The filing of this form does not admit liability or fault. However, failure to file this report with the insurance carrier and provide a copy to the injured worker can result in a citation and civil penalty for each violation as per 24734A-2-407(8), U.C.A. The insurance carrier is to receive the original of this form. The injured worker shall then receive a copy along with their rights and obligations of the Utah222s Workers222 Compensation Act (Form 100). The employer should keep a copy for their records. The Labor Commission, Division of Industrial Accidents, will receive an electronic copy from the insurance carrier. The electronic copy of this form is private information and only released to parties of the claim. In order to dispute the validity of the injured worker222s claim, contact the insurance carrier or claim administrator for more information. All fields on this form are required. Please complete this form entirely and do not leave any blank fields. This form will be returned and additional information will be requested if it is not properly completed. If you, the employer, need assistance to complete the form contact your workers222 compensation insurance carrier or claims administrator. Rule R612 - 200 - 1(A)(2) Except for injuries treated only by first aid, an employer shall report each employee work injury within 7 days after receiving initial notice of the injury, as follows: a. An employer that has obtained workers' compensation insurance shall report the injury to its insurance carrier. b. An employer that has received Division authorization to self-insure shall report the injury to its claims administrator. c. An employer that has failed to obtain worker's compensation coverage shall report the injury by contacting the Division directly. 3. An employer has notice of a work injury upon the earliest of: a. Observation of the injury; b. Verbal or written notice of the injury from any source; or c. Receipt of any other information sufficient to warrant further inquiry by the employer. FRAUD WARNING : Any person who knowingly presents false or fraudulent underwriting information, files, claim for disability compensation, medical benefits, health care fees, or other professional services are of guilty of a crime and may be subject to fines and confinement in state prison. American LegalNet, Inc. www.FormsWorkFlow.com Form 100 INJURED WORKERS222 RIGHTS AND RESPONSIBILITES Revised 1/2019 160 East 300 South 3rd Floor P.O. Box 146610 Salt Lake City, Utah 84114-6610 Office: (801)-530-6800 Fax: (801)-530-6804 Toll Free: (800)-530-5090 www.laborcommission.utah.gov THIS FORM IS TO BE PROVIDED TO THE INJURED WORKER WITH THE INITIAL REPORT OF INJURY RIGHTS Medical Expenses: You are entitled to have all reasonable medical expenses paid that are as a result of a work226 related injury or illness. You may also be eligible for reimbursement for travel to and from approved medical care. Compensation Benefits: You may be entitled to 66-2/3% of your wages up to 100% of the state average weekly wage if the claim is found to be compensable and a physician states you are totally unable to work. No compensation benefits are to be paid in the first three (3) days unless the disability prevents you from working for more than a total of fourteen (14) days. If your work injury or illness prevents you from earning your full wage while you are recovering and working with restrictions, you may be entitled to partial compensation. If you have sustained a permanent impairment due to an industrial injury or disease, you are entitled to disability compensation based on an impairment rating as determined by a physician. If you are permanently and totally disabled from working due to an industrial injury, you may need to apply for a hearing at the Labor Commission to determine if benefits are due. Dependent Benefits: In the case of death of an employee resulting from a work-related injury, workers222 compensation shall pay some funeral and burial expenses. In addition, the deceased worker222s spouse, dependent children, and other dependents may be entitled to monthly payments. Reemployment Assistance: You may be eligible for reemployment assistance if you are unable to return to work due to an industrial injury. Contact the insurance adjuster or the Utah State Office of Rehabilitation for further information at (801) - 887 - 9500 or www.usor.utah.gov . RESPONSIBILITIES : Employer222s Physician: If your employer has a company physician or designated clinic for industrial accidents, you must see the company physician first or you may be obligated to pay for the difference in medical costs. After you have been seen by your employer222s physician, you have the right to change the treating physician once throughout the duration of your claim. Medical Records: You shall comply with rules adopted by the Labor Commission regarding disclosure of your medical records which are relevant to the industrial accident or illness claim, otherwise benefits could be denied. Cooperation: Promptly provide information requested by the insurance adjuster and cooperate with the investigation of your claim. If a claim is denied and you disagree with the denial reason, you may file an application for hearing and an Administrative Law Judge will issue a decision on your claim. Medical Cooperation: You must cooperate with your employer or the insurance adjuster by following prescribed medical treatments / evaluations / visits as to return to work as quickly as possible. Concerns: Contact the insurance adjuster if problems arise concerning your industrial accident claim regarding medical treatment, payment of medical bills, compensation benefits, or work restrictions. If you have any additional questions regarding your rights and responsibilities throughout the duration of the claim process, feel free to contact the Utah Labor Commission, Division of Industrial Accidents. The employer must provide a copy of this form to the injured worker with form 122E Employer222s First Report of Injury. A