Form 04-0101 "Employer's Report of Industrial Injury Form" - Arizona

What Is Form 04-0101?

This is a legal form that was released by the Industrial Commission of Arizona - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2001;
  • The latest edition provided by the Industrial Commission of Arizona;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 04-0101 by clicking the link below or browse more documents and templates provided by the Industrial Commission of Arizona.

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Download Form 04-0101 "Employer's Report of Industrial Injury Form" - Arizona

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EMPLOYER'S REPORT
INDUSTRIAL COMMISSION OF ARIZONA
FOR CARRIER USE ONLY
OF INDUSTRIAL INJURY
P.O. BOX 19070
____________________________________
PHOENIX, ARIZONA 85005-9070
COMPLETE AND MAIL THIS REPORT WITHIN 10
FOR OSHA PURPOSES ONLY
DAYS FROM NOTICE OF ACCIDENT. FATALITIES
MUST BE REPORTED WITHIN 24 HOURS.
MAIL TO: (CARRIER NAME & ADDRESS)
OSHA Case #: _______________________________________
Employer must, on this form, notify his insurance carrier of
every injury or disease suffered by an employee, fatal or
RECORDABLE INJURY
______________________
otherwise, which is claimed to arise out of or in the course of
employment. ARIZONA REVISED STATUTES 23-908 &
NON-RECORDABLE INJURY
______________________
23-1061
EMPLOYEE
1.
LAST NAME
FIRST
M.I.
2.
SOCIAL SECURITY NUMBER*
3.
BIRTH DATE
4.
HOME ADDRESS (NUMBER & STREET)
CITY
STATE
ZIP CODE
5.
TELEPHONE
6.
7.
MARITAL STATUS:
SEX
MALE
FEMALE
SINGLE
MARRIED
DIVORCED
WIDOWED
EMPLOYER
8.
EMPLOYER'S NAME
9.
POLICY NUMBER
10. NATURE OF BUSINESS (MANUFACTURING, ETC.)
11. OFFICE ADDRESS (NUMBER & STREET)
CITY
STATE
ZIP CODE
12. TELEPHONE
13. DATE OF INJURY OR ILLNESS
14. TIME OF EVENT
15. TIME EMPLOYEE BEGAN WORK
16. DATE EMPLOYER NOTIFIED OF INJURY
ACCIDENT
A.M.
P.M.
A.M.
P.M.
17. LAST DAY OF WORK AFTER INJURY
18. DATE OF RETURN TO WORK
19. EMPLOYEE'S OCCUPATION (JOB TITLE) WHEN INJURED
20. CLASS CODE ON PAYROLL REPORT
21. EMPLOYEE'S ASSIGNED DEPARTMENT
22. DEPARTMENT NUMBER
23. DID INJURY OCCUR ON EMPLOYER PREMISES?
YES
NO
24. ADDRESS OR LOCATION OF ACCIDENT
CITY
COUNTY
STATE
ZIP CODE
Examples: "strained back"; "chemical burn, hand";
25. WHAT WAS THE INJURY OR ILLNESS? Tell us the part of the body that was affected and how it was affected; be more specific than "hurt," "pain," or sore."
"carpal tunnel syndrome."
26. PART OF BODY INJURED
27. FATAL
28. IF THE EMPLOYEE DIED, WHEN DID THE DEATH OCCUR? DATE OF DEATH
YES
NO
29. WAS EMPLOYEE TREATED IN AN EMERGENCY
NAME OF PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL
ADDRESS (STREET, CITY, STATE & ZIP CODE)
ROOM?
YES
NO
30. WAS EMPLOYEE HOSPITALIZED OVERNIGHT
IF HOSPITALIZED, HOSPITAL NAME
ADDRESS (STREET, CITY, STATE & ZIP CODE)
AS AN IN-PATIENT?
YES
NO
31. IF VALIDITY OF CLAIM IS DOUBTED, STATE REASON
CAUSE OF
Examples:
32. WHAT HAPPENED? Tell us how the injury occurred.
"When ladder slipped on wet floor, worker fell 20 feet"; "Worker was sprayed with chlorine when gasket broke during replacement";
"Worker developed soreness in wrist over time."
ACCIDENT
Examples:
If this question does not apply to the incident, leave it blank.
33. WHAT OBJECT OR SUBSTANCE DIRECTLY HARMED THE EMPLOYEE?
"concrete floor"; "chlorine"; "radial arm saw."
Examples:
34. WHAT WAS EMPLOYEE DOING JUST BEFORE THE INCIDENT OCCURRED? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific.
"climbing a ladder while
carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-entry."
35. IF ANOTHER PERSON NOT IN COMPANY EMPLOY CAUSED ACCIDENT, GIVE NAME AND ADDRESS
36. WAS WORKER IN YOUR EMPLOY
37. HOURS PER DAY EMPLOYEE WORKED
38. WAS EMPLOYEE ON OVERTIME
39. NUMBER OF DAYS PER WEEK
EMPLOYEE'S
WHEN INJURED?
WHEN INJURED?
USUALLY WORKED
WAGE DATA
YES
NO
YES
NO
FROM
A.M.
P.M.
THRU
A.M.
P.M.
EMPLOYEE
COMPANY
IF WORK LOSS IS EXPECTED TO EXCEED SEVEN
40. DATE OF LAST HIRE
41. WAS WORKER PAID FOR DAY OF INJURY?
42. WAS EMPLOYEE HIRED FOR PERMANENT
IMPORTANT
CALENDAR DAYS, COMPLETE ITEMS 40 THRU 47
EMPLOYMENT?
$
YES
NO
IF YES,
YES
NO
43. NUMBER OF MONTHS EMPLOYMENT
44. GIVE EMPLOYEE'S WAGE STATUS AS APPLICABLE
45. IS EMPLOYEE FURNISHED
VALUE
AVAILABLE DURING THE YEAR
HOUR
DAY
WEEK
MONTH
$
$
per
LODGING
BOARD
BOTH
46. ACTUAL GROSS EARNINGS OF EMPLOYEE FOR THE 30 CALENDAR DAYS PRECEDING INJURY
47. DOES EMPLOYEE CLAIM DEPENDENTS?
YES
NO
(EXAMPLE: IF INJURED APRIL 8, GIVE EARNINGS FROM MARCH 9 THRU APRIL 7)
IF EMPLOYEE IS PAID OTHER THAN FIXED WEEKLY
48. IF EMPLOYEE EARNS EXTRA PAY FOR OVERTIME, WHAT IS
49. NUMBER OF HOURS OVERTIME CONSIDERED NORMAL PER
IMPORTANT
OR MONTHLY SALARY, COMPLETE ITEMS 48 THRU 55
BASIS OF PAYMENT?
WEEK
PER HOUR
50
GROSS WAGES OF EMPLOYEE DURING 12 MONTHS PRECEEDING INJURY
51. IF EMPLOYEE WORKED LESS THAN 12 MONTHS, SHOW GROSS WAGES FROM DATE OF HIRE
THROUGH DAY PRIOR TO INJURY
$
$
FROM
THRU
FROM
THRU
52. DATE OF LAST WAGE INCREASE IF
53. WAGE BEFORE INCREASE
54. WAGE AFTER INCREASE
55. GROSS EARNINGS FROM DATE OF INCREASE THRU DAY PRIOR TO INJURY
WITHIN 12 MONTHS PRIOR TO INJURY
$
$
$
DATE
AUTHORIZED SIGNATURE
TITLE
AUTHORIZED
SIGNATURE
NOTE TO EMPLOYER:
1.
Mail one copy to the Industrial Commission within 10 days.
2.
Mail one copy to your insurance carrier within 10 days.
3.
Keep one copy, for not less than five (5) years, as your supplementary record of
injuries required by the Federal Occupational Safety and Health Act of 1970.
* The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted by Section 7(a)(2)(B) of the Federal Privacy
Act of 1974, because the Commission's forms, prescribed under the Commission's rules in existence prior to January 1, 1975, required disclosure of the social security number. The number is used as a means of identifying all the
various records in the Claims Division or Special Fund pertaining to an individual. The use of social security numbers is made necessary because of the large number of persons who have similar names and birth dates, and whose
identities can only be distinguished by the social security number.
THIS FORM APPROVED BY THE INDUSTRIAL COMMISSION OF ARIZONA FOR CARRIER USE
Form ICA 04-0101 (Rev. 7/01)
WC 8418e (7-01)
UNIFORM INFORMATION SERVICES, INC.
EMPLOYER'S REPORT
INDUSTRIAL COMMISSION OF ARIZONA
FOR CARRIER USE ONLY
OF INDUSTRIAL INJURY
P.O. BOX 19070
____________________________________
PHOENIX, ARIZONA 85005-9070
COMPLETE AND MAIL THIS REPORT WITHIN 10
FOR OSHA PURPOSES ONLY
DAYS FROM NOTICE OF ACCIDENT. FATALITIES
MUST BE REPORTED WITHIN 24 HOURS.
MAIL TO: (CARRIER NAME & ADDRESS)
OSHA Case #: _______________________________________
Employer must, on this form, notify his insurance carrier of
every injury or disease suffered by an employee, fatal or
RECORDABLE INJURY
______________________
otherwise, which is claimed to arise out of or in the course of
employment. ARIZONA REVISED STATUTES 23-908 &
NON-RECORDABLE INJURY
______________________
23-1061
EMPLOYEE
1.
LAST NAME
FIRST
M.I.
2.
SOCIAL SECURITY NUMBER*
3.
BIRTH DATE
4.
HOME ADDRESS (NUMBER & STREET)
CITY
STATE
ZIP CODE
5.
TELEPHONE
6.
7.
MARITAL STATUS:
SEX
MALE
FEMALE
SINGLE
MARRIED
DIVORCED
WIDOWED
EMPLOYER
8.
EMPLOYER'S NAME
9.
POLICY NUMBER
10. NATURE OF BUSINESS (MANUFACTURING, ETC.)
11. OFFICE ADDRESS (NUMBER & STREET)
CITY
STATE
ZIP CODE
12. TELEPHONE
13. DATE OF INJURY OR ILLNESS
14. TIME OF EVENT
15. TIME EMPLOYEE BEGAN WORK
16. DATE EMPLOYER NOTIFIED OF INJURY
ACCIDENT
A.M.
P.M.
A.M.
P.M.
17. LAST DAY OF WORK AFTER INJURY
18. DATE OF RETURN TO WORK
19. EMPLOYEE'S OCCUPATION (JOB TITLE) WHEN INJURED
20. CLASS CODE ON PAYROLL REPORT
21. EMPLOYEE'S ASSIGNED DEPARTMENT
22. DEPARTMENT NUMBER
23. DID INJURY OCCUR ON EMPLOYER PREMISES?
YES
NO
24. ADDRESS OR LOCATION OF ACCIDENT
CITY
COUNTY
STATE
ZIP CODE
Examples: "strained back"; "chemical burn, hand";
25. WHAT WAS THE INJURY OR ILLNESS? Tell us the part of the body that was affected and how it was affected; be more specific than "hurt," "pain," or sore."
"carpal tunnel syndrome."
26. PART OF BODY INJURED
27. FATAL
28. IF THE EMPLOYEE DIED, WHEN DID THE DEATH OCCUR? DATE OF DEATH
YES
NO
29. WAS EMPLOYEE TREATED IN AN EMERGENCY
NAME OF PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL
ADDRESS (STREET, CITY, STATE & ZIP CODE)
ROOM?
YES
NO
30. WAS EMPLOYEE HOSPITALIZED OVERNIGHT
IF HOSPITALIZED, HOSPITAL NAME
ADDRESS (STREET, CITY, STATE & ZIP CODE)
AS AN IN-PATIENT?
YES
NO
31. IF VALIDITY OF CLAIM IS DOUBTED, STATE REASON
CAUSE OF
Examples:
32. WHAT HAPPENED? Tell us how the injury occurred.
"When ladder slipped on wet floor, worker fell 20 feet"; "Worker was sprayed with chlorine when gasket broke during replacement";
"Worker developed soreness in wrist over time."
ACCIDENT
Examples:
If this question does not apply to the incident, leave it blank.
33. WHAT OBJECT OR SUBSTANCE DIRECTLY HARMED THE EMPLOYEE?
"concrete floor"; "chlorine"; "radial arm saw."
Examples:
34. WHAT WAS EMPLOYEE DOING JUST BEFORE THE INCIDENT OCCURRED? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific.
"climbing a ladder while
carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-entry."
35. IF ANOTHER PERSON NOT IN COMPANY EMPLOY CAUSED ACCIDENT, GIVE NAME AND ADDRESS
36. WAS WORKER IN YOUR EMPLOY
37. HOURS PER DAY EMPLOYEE WORKED
38. WAS EMPLOYEE ON OVERTIME
39. NUMBER OF DAYS PER WEEK
EMPLOYEE'S
WHEN INJURED?
WHEN INJURED?
USUALLY WORKED
WAGE DATA
YES
NO
YES
NO
FROM
A.M.
P.M.
THRU
A.M.
P.M.
EMPLOYEE
COMPANY
IF WORK LOSS IS EXPECTED TO EXCEED SEVEN
40. DATE OF LAST HIRE
41. WAS WORKER PAID FOR DAY OF INJURY?
42. WAS EMPLOYEE HIRED FOR PERMANENT
IMPORTANT
CALENDAR DAYS, COMPLETE ITEMS 40 THRU 47
EMPLOYMENT?
$
YES
NO
IF YES,
YES
NO
43. NUMBER OF MONTHS EMPLOYMENT
44. GIVE EMPLOYEE'S WAGE STATUS AS APPLICABLE
45. IS EMPLOYEE FURNISHED
VALUE
AVAILABLE DURING THE YEAR
HOUR
DAY
WEEK
MONTH
$
$
per
LODGING
BOARD
BOTH
46. ACTUAL GROSS EARNINGS OF EMPLOYEE FOR THE 30 CALENDAR DAYS PRECEDING INJURY
47. DOES EMPLOYEE CLAIM DEPENDENTS?
YES
NO
(EXAMPLE: IF INJURED APRIL 8, GIVE EARNINGS FROM MARCH 9 THRU APRIL 7)
IF EMPLOYEE IS PAID OTHER THAN FIXED WEEKLY
48. IF EMPLOYEE EARNS EXTRA PAY FOR OVERTIME, WHAT IS
49. NUMBER OF HOURS OVERTIME CONSIDERED NORMAL PER
IMPORTANT
OR MONTHLY SALARY, COMPLETE ITEMS 48 THRU 55
BASIS OF PAYMENT?
WEEK
PER HOUR
50
GROSS WAGES OF EMPLOYEE DURING 12 MONTHS PRECEEDING INJURY
51. IF EMPLOYEE WORKED LESS THAN 12 MONTHS, SHOW GROSS WAGES FROM DATE OF HIRE
THROUGH DAY PRIOR TO INJURY
$
$
FROM
THRU
FROM
THRU
52. DATE OF LAST WAGE INCREASE IF
53. WAGE BEFORE INCREASE
54. WAGE AFTER INCREASE
55. GROSS EARNINGS FROM DATE OF INCREASE THRU DAY PRIOR TO INJURY
WITHIN 12 MONTHS PRIOR TO INJURY
$
$
$
DATE
AUTHORIZED SIGNATURE
TITLE
AUTHORIZED
SIGNATURE
NOTE TO EMPLOYER:
1.
Mail one copy to the Industrial Commission within 10 days.
2.
Mail one copy to your insurance carrier within 10 days.
3.
Keep one copy, for not less than five (5) years, as your supplementary record of
injuries required by the Federal Occupational Safety and Health Act of 1970.
* The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted by Section 7(a)(2)(B) of the Federal Privacy
Act of 1974, because the Commission's forms, prescribed under the Commission's rules in existence prior to January 1, 1975, required disclosure of the social security number. The number is used as a means of identifying all the
various records in the Claims Division or Special Fund pertaining to an individual. The use of social security numbers is made necessary because of the large number of persons who have similar names and birth dates, and whose
identities can only be distinguished by the social security number.
THIS FORM APPROVED BY THE INDUSTRIAL COMMISSION OF ARIZONA FOR CARRIER USE
Form ICA 04-0101 (Rev. 7/01)
WC 8418e (7-01)
UNIFORM INFORMATION SERVICES, INC.