EMPLOYER’S REPORT OF INDUSTRIAL INJURY ~ Salesforce

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EMPLOYER’S REPORT OF INDUSTRIAL INJURY

COMPLETE AND SUBMIT THIS REPORT WITHIN 10 DAYS FROM NOTICE OF ACCIDENT. FATALITIES MUST BE REPORTED WITHIN 24 HOURS.

Employer must, on this form, notify his insurance carrier of every injury or disease suffered by an employee, fatal or otherwise, which is claimed to arise out of or in the course of employment. ARIZONA REVISED STATUTES 23-908 and 23-1061

= Required Information

EMPLOYEE

LAST NAME
FIRST
M.I.
SOCIAL SECURITY NUMBER*
BIRTH DATE
HOME ADDRESS(NUMBER AND STREET)

*City
STATE

ZIP CODE
TELEPHONE
SEX		MARITAL STATUS

EMPLOYER

EMPLOYER'S NAME

FEIN NUMBER

POLICY NUMBER

NATURE OF BUSINESS(MANUFACTURING,ETC.)

OFFICE ADDRESS(NUMBER & STREET)

*City
STATE

ZIP CODE
TELEPHONE

ACCIDENT DETAILS

DATE OF INJURY OR ILLNESS

[ 5/5/2021 ]

TIME OF EVENT

DATE EMPLOYER NOTIFIED OF INJURY

[ 5/5/2021 ]

TIME EMPLOYEE BEGAN WORK

LAST DAY OF WORK AFTER INJURY

[ 5/5/2021 ]

HAS EMPLOYEE RETURNED TO WORK?

Yes

DATE OF RETURN TO WORK

[ 5/5/2021 ]

EMPLOYEE'S OCCUPATION(JOB TITLE) WHEN INJURED

CLASS CODE ON PAYROLL REPORT

EMPLOYEE’S ASSIGNED DEPARTMENT

DEPARTMENT NUMBER

DID INJURY OCCUR ON EMPLOYER PREMISES?

ADDRESS OR LOCATION OF ACCIDENT

City
COUNTY
STATE

ZIP CODE
WHAT WAS THE INJURY OR ILLNESS?
PART OF BODY INJURED	PART OF BODY INJURY TABLE	Part of Body Injured List

FATAL	IF THE EMPLOYEE DIED, WHEN DID THE DEATH OCCUR? DATE OF DEATH	[ 5/5/2021 ]

WAS EMPLOYEE TREATED IN AN EMERGENCY ROOM?
NAME OF PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL
ADDRESS

City
STATE

ZIP CODE
WAS EMPLOYEE HOSPITALIZED OVERNIGHT AS AN IN-PATIENT?
IF HOSPITALIZED, HOSPITAL NAME
ADDRESS

City
STATE

ZIP CODE
IS VALIDITY OF CLAIM DOUBTED		IF YES, STATE REASON

CAUSE OF ACCIDENT

WHAT HAPPENED?
WHAT OBJECT OR SUBSTANCE DIRECTLY HARMED THE EMPLOYEE?
NATURE OF INJURY	Nature of Injury List	CAUSE OF INJURY	Cause of Injury List
WHAT WAS EMPLOYEE DOING JUST BEFORE THE INCIDENT OCCURRED?
IF ANOTHER PERSON NOT IN COMPANY EMPLOY CAUSED ACCIDENT, GIVE NAME AND ADDRESS
WAS WORKER IN YOUR EMPLOY WHEN INJURED?		DATE OF LAST HIRE	[ 5/5/2021 ]

EMPLOYEE'S WAGE DATA

HOURS PER DAY EMPLOYEE WORKED
FROM		THRU
WAS EMPLOYEE ON OVERTIME WHEN INJURED?
NUMBER OF DAYS PER WEEK USUALLY WORKED
EMPLOYEE		COMPANY
WAS WORKER PAID FOR DAY OF INJURY?		AMOUNT PAID FOR DAY OF INJURY
WAS EMPLOYEE HIRED FOR PERMANENT EMPLOYMENT?		NUMBER OF MONTHS EMPLOYMENT AVAILABLE DURING THE YEAR
EMPLOYEE'S WAGE AMOUNT AS APPLICABLE		GIVE EMPLOYEE’S WAGE STATUS AS APPLICABLE
IS EMPLOYEE FURNISHED		VALUE
ACTUAL GROSS EARNINGS OF EMPLOYEE FOR THE 30 CALENDAR DAYS PRECEEDING INJURY		DOES EMPLOYEE CLAIM DEPENDENTS?

IF EMPLOYEE IS PAID OTHER THAN FIXED WEEKLY OR MONTHLY SALARY, COMPLETE ITEMS IN BELOW SECTION

IF EMPLOYEE EARNS EXTRA PAY FOR OVERTIME, WHAT IS BASIS OF PAYMENT PER HOUR?		NUMBER OF HOURS OVERTIME CONSIDERED NORMAL PER WEEK

DATE OF HIRE GREATER THAN ONE YEAR PRIOR TO INJURY, COMPLETE THE FOLLOWING.IF NOT, SKIP TO NEXT QUESTION.

GROSS WAGES OF EMPLOYEE DURING 12 MONTHS PRECEEDING INJURY
FROM	[ 5/5/2021 ]	THRU	[ 5/5/2021 ]
$

DATE OF HIRE LESS THAN ONE YEAR, COMPLETE THE FOLLOWING. IF NOT,SKIP TO NEXT QUESTION.

IF EMPLOYEE WORKED LESS THAN 12 MONTHS, SHOW GROSS WAGES FROM DATE OF HIRE THROUGH DAY PRIOR TO INJURY
FROM	[ 5/5/2021 ]	THRU	[ 5/5/2021 ]
$

COMPLETE IF EMPLOYEE RECEIVED A WAGE INCREASE IN LAST 12 MONTHS PRIOR TO INJURY

DATE OF LAST WAGE INCREASE IF WITHIN 12 MONTHS PRIOR TO INJURY	[ 5/5/2021 ]	WAGE BEFORE INCREASE
WAGE AFTER INCREASE		GROSS EARNINGS FROM DATE OF INCREASE THRU DAY PRIOR TO INJURY

AUTHORIZED SIGNATURE

TITLE

SUBMITTER EMAIL ADDRESS

DOCUMENT TYPE FOR FILE UPLOAD
UPLOAD FILE
( Supported formats are .pdf, .png, .jpeg, .jpg, .tiff )

NOTE TO EMPLOYER:

1. Submit one copy to the Industrial Commission within 10 days.
2. Submit 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 0101 - Rev 6/2019

By signing this form electronically, I certify that I am an interested party or an authorized representative of an interested party. I further certify that I am authorized to sign this form and that all of the representations included in this form are true, accurate, and complete.

I agree

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