Form preview

Get the free first report of injury utah form

Get Form
EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS Form 122 Print Form Filing this form is not an admission of liability for the claim. Employer Name Address Include Zip G E N R A L W Report Purpose Code Jurisdiction Claim Number Insured Report Number Employer s Location Address If Different Industry Code D M I P O Y OSHA Log Number C S Carrier/Administrator Claim Number Location Number Employer FEIN Phone Number CARRIER/CLAIMS ADMINISTRATOR Carrier Nam...
We are not affiliated with any brand or entity on this form

Get, Create, Make and Sign

Edit
Edit your first report of injury form online
Type text, complete fillable fields, insert images, highlight or blackout data for discretion, add comments, and more.
Add
Add your legally-binding signature
Draw or type your signature, upload a signature image, or capture it with your digital camera.
Share
Share your form instantly
Email, fax, or share your first report of injury form via URL. You can also download, print, or export forms to your preferred cloud storage service.

How to edit first report of injury utah online

9.5
Ease of Setup
pdfFiller User Ratings on G2
9.0
Ease of Use
pdfFiller User Ratings on G2
Follow the steps down below to benefit from the PDF editor's expertise:
1
Check your account. If you don't have a profile yet, click Start Free Trial and sign up for one.
2
Upload a file. Select Add New on your Dashboard and upload a file from your device or import it from the cloud, online, or internal mail. Then click Edit.
3
Edit first report of injury utah. Replace text, adding objects, rearranging pages, and more. Then select the Documents tab to combine, divide, lock or unlock the file.
4
Save your file. Select it from your list of records. Then, move your cursor to the right toolbar and choose one of the exporting options. You can save it in multiple formats, download it as a PDF, send it by email, or store it in the cloud, among other things.
Dealing with documents is always simple with pdfFiller.

How to fill out first report of injury

Illustration
01
To fill out the first report of injury, start by collecting all relevant information about the injured person, such as their full name, contact information, and employee identification number if applicable.
02
Next, document the date, time, and location of the injury. It is important to be as specific as possible to provide an accurate account of the incident.
03
Describe in detail the nature of the injury and how it occurred. Include any contributing factors or hazardous conditions that may have led to the incident.
04
If there were any witnesses present, record their names and contact information. Their statements can provide additional evidence or clarity regarding the incident.
05
If the injured person sought medical attention, document the healthcare provider's name, contact information, and any treatment received. Include details about any diagnosed injuries or conditions resulting from the incident.
06
Additionally, include any steps taken to mitigate the situation or prevent further injuries. This could include providing first aid, notifying a supervisor or safety personnel, or implementing any necessary changes to prevent similar incidents in the future.
07
Finally, sign and date the report to certify its accuracy. It is important to submit the report promptly according to your organization's policies or legal requirements.

Who needs the first report of injury?

01
Employers: The first report of injury is typically required by employers to ensure compliance with workers' compensation laws and to initiate the claim process.
02
Insurance companies: In order to process a workers' compensation claim, insurance companies often require the first report of injury to assess the validity of the claim and determine appropriate compensation.
03
Medical professionals: Healthcare providers may need the first report of injury to understand the circumstances surrounding the injury and provide appropriate treatment. This information can also help determine if the injury is work-related for insurance purposes.
04
Legal entities: In some cases, legal entities may request the first report of injury as part of a legal proceeding or to investigate any potential liability or negligence claims.
It is important to consult with your organization's policies and local regulations to determine who specifically needs the first report of injury in your specific situation.

Fill form : Try Risk Free

Rate free

4.0
Satisfied
44 Votes

People Also Ask about first report of injury utah

For pdfFiller’s FAQs

Below is a list of the most common customer questions. If you can’t find an answer to your question, please don’t hesitate to reach out to us.

A First Report of Injury (FROI) is a document used to report a work-related injury or illness to an employer or insurance provider. It is typically the first step in initiating an insurance claim for workers' compensation benefits. The FROI includes details about the injury, such as the date, time, and location, as well as information about the employee and the circumstances surrounding the incident. This report is important for documenting the injury, ensuring that appropriate medical and financial assistance is provided to the employee, and determining the employer's liability.
The employer or the injured employee is required to file the first report of injury.
The penalty for the late filing of a first report of injury can vary depending on the jurisdiction and specific circumstances. In some cases, there may be a monetary fine imposed on the employer or insurer for late reporting. Additionally, late filing could result in delays or denial of benefits for the injured employee. It is essential to consult the specific laws and regulations governing workers' compensation in your jurisdiction for accurate and up-to-date information regarding penalties.
The purpose of the first report of injury is to notify an employer or insurance company about an employee's work-related injury or illness. It is a formal document that provides details about the incident, including the date, time, location, and nature of the injury, as well as the employee's personal information and any witnesses present. This report serves as the initial record of the injury and is typically required to initiate the process of filing a workers' compensation claim, ensuring that the injured employee receives appropriate medical treatment and compensation if necessary. Additionally, the first report of injury helps employers track and analyze workplace incidents to identify potential hazards and implement preventive measures for future safety improvements.
To fill out a first report of injury form, follow these steps: 1. Obtain the necessary form: Contact your employer or Human Resources department to obtain the specific form they require for reporting workplace injuries. Alternatively, check your company's intranet or website to see if the form is available digitally. 2. Gather relevant information: Collect all the relevant details related to the injury. This includes the date and time of the incident, the location where it occurred, the names of any witnesses, and a description of what happened. Try to be as specific and detailed as possible. 3. Provide personal information: Fill in your personal details such as your full name, employee ID, contact information, and job title. Ensure accuracy in this section as it helps identify the injured employee. 4. Describe the injury: Give a detailed description of the injury itself, including the body parts affected and the severity of the injury. If medical treatment was sought, provide information about the healthcare provider visited and the treatment provided. 5. Include witness statements: If there were any witnesses to the incident, it can be helpful to include their statements. This adds credibility to your report and provides additional perspectives on what occurred. 6. Submit the form: After completing the form, sign and date it. Keep a copy for your records and submit the original to the appropriate department within your organization. If in doubt about where to send it, consult your Human Resources department. Remember to complete the report as soon as possible after the incident to ensure accuracy and to comply with any deadlines set by your employer or local regulations.
The premium version of pdfFiller gives you access to a huge library of fillable forms (more than 25 million fillable templates). You can download, fill out, print, and sign them all. State-specific first report of injury utah and other forms will be easy to find in the library. Find the template you need and use advanced editing tools to make it your own.
pdfFiller makes it easy to finish and sign first report of injury utah online. It lets you make changes to original PDF content, highlight, black out, erase, and write text anywhere on a page, legally eSign your form, and more, all from one place. Create a free account and use the web to keep track of professional documents.
With pdfFiller, you may not only alter the content but also rearrange the pages. Upload your first report of injury utah and modify it with a few clicks. The editor lets you add photos, sticky notes, text boxes, and more to PDFs.

Fill out your first report of injury online with pdfFiller!

pdfFiller is an end-to-end solution for managing, creating, and editing documents and forms in the cloud. Save time and hassle by preparing your tax forms online.

Get started now
Form preview

Related Forms