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 file 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 Identification Number ________________________________________ Date of hire __________________ _ 2. Name of employer ___________________________________________________________ Phone ______________________ _ 3. Mailing address___________________________________________________________________________________________________________ City State ZIP Code Street 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 ___________________________ FOR OFFICE USE 6. Name of employee _________________________________________________________________________________ Age______ Sex______ First Middle Last 7. Home address ___________________________________________________________________________________________________________ City State ZIP Code Street COUNTY Birth Employee's Home 8. SSN_____________________ date________________ occupation________________________________ phone _________________________ 9. Date of injury or occupational disease__________________ Time of injury_________ a.m. p.m. CAUSE 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 NATURE ­­­­­­ SEVERITY 12. How did accident occur? ___________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ 0 - NO TIME LOST 1 - TIME LOST 13. What was employee doing when injured? ______________________________________________________________________________________ 2 - MEDICAL 3 - FATAL ________________________________________________________________________________________________________________________ 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 SOURCE MEMBER 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 first/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_____________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 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 benefits to the injured employees and could subject the employer to fines. Mail or fax the original report only. If not completed using the fillable 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 specific as possible indicating all that is known about the injury. Name the part of body injured. Definition of an Incapacitating Injury The Workers’ Compensation Act sets forth a strict time frame for filing 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 sufficient 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 filed 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 specifically defined 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 filing a report that ultimately proves to be unnecessary. There are penalties, however, for failing to file a report when one was required. The penalties include fines and limitations on the defenses the employer may assert if a claim is filed. 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 file for five (5) years. To learn more about OSHA's recordkeeping requirements and download forms, visit: www.osha.gov/recordkeeping/RKforms.html American LegalNet, Inc. www.FormsWorkFlow.com