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In the realm of occupational safety and health, precise documentation plays a pivotal role in ensuring that both employees and employers navigate the aftermath of workplace incidents with clarity and support. The Indiana State 34401 form serves as a critical tool within this ecosystem, designed to meticulously record the first report of an employee's injury or illness. It encompasses a wide array of detailed instructions encouraging the comprehensive entry of relevant data—from the personal information of the involved employee, such as their social security number, job title, and the specifics of their employment, to the nuanced details of the occurrence, including the date, time, and nature of the injury or illness. Beyond mere factual reporting, the form extends into operational parameters like the identification of agents, categorization of the event per various coding systems (e.g., NCCI and SIC codes), and stipulations regarding the reporting process itself, emphasizing electronic submissions through approved EDI processes. Additionally, it underscores the necessity of employer participation in reporting, nuanced by penalties for non-compliance, thereby reinforcing the form's significance in promoting workplace safety and compliance with state regulations. Essential contacts, from claims administrators to healthcare providers, are identified to streamline the process of claims administration and ensure all parties are duly informed. The integration of these elements within the form not only facilitates a structured response to workplace incidents but also aids in the broader objective of maintaining a safe, healthy, and legally compliant working environment.

Example - Indiana State 34401 Form

INSTRUCTIONS

General Instructions:

1.Please enter information into all of the areas of the First Report form, except the boxes at the top right corner of the form which is for office use only.

2.Enter all dates in MM/DD/YY format.

3.Please return completed form electronically by an approved EDI process.

4.For answers to questions, please call (317) 232-3808.

Definitions:

AGENT NAME AND CODE NUMBER: Enter the name of your insurance agent and his / her code number if known. This information can be found on your insurance policy.

ALL EQUIPMENT, MATERIALS OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR EXPOSURE OCCURRED: List anything the employee was using, applying, handling or operating when the injury or exposure occurred. If the injury involves a fall, indicate any surfaces and / or objects the claimant fell on and where they fell from. Enter “NA” if no equipment, materials or chemicals were being used (e.g. Acetylene cutting torch, metal plate, etc.).

AVG WG/WK: Claimant’s average weekly wage, calculated by totaling the latest 52 weeks of wages (including overtime, tips, etc.) and dividing by 52.

CLAIMS ADMINISTRATOR: Enter the name of the carrier, third-party administrator, state fund, or self-insured responsible for administering the claim.

CONTACT NAME / TELEPHONE NUMBER: Enter the name of the individual at the employer’s premises to be contacted for additional information (i.e. Supervisor, HR Person, Nurse, etc.)

DATE DISABILITY BEGAN: The first day on which the claimant originally lost time from work due to the occupational injury or disease or as otherwised deigned by statute.

DEPARTMENT OR LOCATION WHERE ACCIDENT OR EXPOSURE OCCURRED: If the accident or exposure did not occur on the employer’s premises, enter address or location. Be specific (e.g. Maintenance, Client’s Office, Cafeteria, etc.).

EMPLOYEE STATUS: Indicate the employee’s work status from the following choices: Full-time, Part-time, Apprentice Full-time, Apprentice Part-time, Volunteer, Seasonal Worker, Piece Worker, On-Strike, Disabled, Retired, Not Employed or Unknown (you may also abbreviate the above as: (FT, PT, AFT, APT, VO, SW, PW, OS, DI, RE, NE, or UK).

HOW INJURY / ILLNESS OCCURRED: Describe the sequence of events leading to the injury or exposure (e.g. Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, he brushed against the hot metal; Worker stepped to the edge of the scaffolding, lost balance and fell six feet to the concrete floor. The worker’s right wrist was broken in the fall).

NCCI CLASS CODE: A four-digit code classifying the occupation of the claimant.

OCCUPATION / JOB TITLE: Enter the primary occupation of the claimant at the time of the accident or exposure.

PART OF BODY AFFECTED: Indicate the part of body affected by the injury / illness (e.g. Right forearm, Low Back, etc.)

REPORT PURPOSE CODE: 00 = Original First Report of Injury; 02 = Updated or Amended First Report.

RTW DATE (Return to Work Date): Enter the date following the most recent disability period on which the employee returned to work.

SIC CODE: This is the code which represents the nature of the employer’s business which is contained in the Standard Industrial Classification Manual published by the Federal Office of Management and Budget.

SPECIFIC ACTIVITY EMPLOYEE ENGAGED IN DURING ACCIDENT / EXPOSURE: Describe the specific activity the employee was engaged in during the accident or exposure (e.g. Cutting metal plate for flooring, sanding ceiling woodwork in preparation for painting).

TYPE OF INJURY / ILLNESS: Briefly describe the nature of the injury or illness (e.g. Contusion, Laceration, Fracture, etc.)

WORK PROCESS THE EMPLOYEE WAS ENGAGED IN DURING ACCIDENT / EXPOSURE: Enter “NA” if employee was not engaged

in a work process, such as if walking down the hallway (e.g. Building maintenance).

INDIANA WORKER’S COMPENSATION

FIRST REPORT OF EMPLOYEE INJURY, ILLNESS

State Form 34401 (R10 / 1-02)

FOR WORKER’S COMPENSATION BOARD USE ONLY

Jurisdiction

Jurisdiction claim number

Process date

 

 

 

Please return completed form electronically by an approved EDI process.

PLEASE TYPE or PRINT IN INK

NOTE: Your Social Security number is being requested by this state agency in order to pursue its statutory responsibilities. Disclosure is voluntary and you will not be penalized for refusal.

EMPLOYEE INFORMATION

Social Security number

Date of birth

 

Sex

 

 

 

Occupation / Job title

 

 

 

NCCI class code

 

 

 

 

Male

Female

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (last, first, middle)

 

 

 

 

Marital status

Date hired

 

State of hire

 

Employee status

 

 

 

 

 

 

 

Unmarried

 

 

 

 

 

 

 

 

Address (number and street, city, state, ZIP code)

 

 

 

Married

Hrs / Day

Days / Wk

 

Avg Wg / Wk

 

 

Paid Day of Injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Separated

 

 

 

 

 

 

Salary Continued

 

 

 

 

 

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wage

Per

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hour

Day

 

Month

Telephone number (include area

 

 

Number of dependents

$

 

 

Week

 

 

 

 

 

 

 

 

 

 

Year

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER INFORMATION

Name of employer

Employer ID#

SIC code

Insured report number

Address of employer (number and street, city, state, ZIP code)

Location number

Employer’s location address (if different)

Telephone number

Carrier / Administrator claim number

OSHA log number

Report purpose code

Actual location of accident / exposure (if not on employer’s premises)

CARRIER / CLAIMS ADMINISTRATOR INFORMATION

Name of claims administrator

Carrier federal ID number

Check if appropriate

 

 

 

Self Insurance

Address of claims administrator (number and street, city, state, ZIP code)

 

Policy / Self-insured number

 

 

Insurance Carrier

 

 

Telephone number

Third Party Admin.

Policy period

 

 

 

From

To

Name of agent

Code number

OCCURRENCE / TREATMENT INFORMATION

Date of Inj./ Exp.

Time of occurrence

AM PM

Date employer notified

 

Type of injury / exposure

 

Type code

 

Cannot be determined

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last work date

Time workday began

 

Date disability began

 

Part of body

 

Part code

 

 

 

 

 

 

 

 

 

 

RTW date

Date of death

 

Injury / Exposure occurred

Yes

Name of contact

Telephone number

 

 

 

on employer’s premises?

No

 

 

 

 

 

 

 

 

 

 

 

 

 

Department or location where accident / exposure occurred

 

 

 

 

All equipment, materials, or chemicals involved in accident

 

 

 

 

 

 

 

 

Specific activity engaged in during accident / exposure

 

 

 

 

Work process employee engaged in during accident / exposure

 

 

 

 

 

 

How injury / exposure occurred. Describe the sequence of events and include any relevant objects or substances.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cause of injury code

 

 

 

 

 

 

 

 

 

 

Name of physician / health care provider

Hospital or offsite treatment (name and address)

Name of witness

 

Telephone number

Date administrator notified

 

 

 

 

 

 

Date prepared

Name of preparer

 

Title

 

Telephone number

 

 

 

 

 

 

INITIAL TREATMENT

No Medical Treatment

Minor: By Employer

Minor: Clinic / Hospital

Emergency Care

Hospitalized > 24 Hours

Future Major Medical / Lost

Time Anticipated

An employer’s failure to report an occupational injury or illness may result in a $50 fine (IC 22-3-4-13).

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File Information

Fact Detail
Form Identification Indiana Worker’s Compensation First Report of Employee Injury, Illness State Form 34401 (R10 / 1-02)
Purpose To report an occupational injury or illness to the Indiana Worker’s Compensation Board.
Submission Method Must be returned electronically by an approved EDI process.
Data Format for Dates Dates must be entered in MM/DD/YY format.
Contact for Questions Questions should be directed to (317) 232-3808.
Penalty for Non-compliance An employer’s failure to report may result in a $50 fine as per IC 22-3-4-13.
Governing Law Indiana Workers' Compensation Act, specifically IC 22-3-4-13 for reporting requirements and penalties.
Information Required Includes extensive employee, employer, and injury details, such as type of injury, location, date and time of occurrence.
Additional Information Specifies need for description of how injury occurred, and any equipment, materials, or chemicals involved.
Unique Elements Requires NCCI class code, SIC code, and employee status (e.g., Full-time, Part-time) for comprehensive injury reporting.
Initial Treatment Options Captures information on the initial treatment provided, ranging from no medical treatment to hospitalization.

How to Fill Out Indiana State 34401

Once the Indiana State Form 34401 is in your hands, you've taken the first step towards properly documenting an employee's injury or illness for worker's compensation purposes. The form requires detailed information but completing it correctly is crucial for a smooth process. Let's walk through the steps necessary to fill out this form accurately and efficiently.

  1. Begin with "Employee Information": Enter the Social Security number, date of birth, sex, occupation/job title, and NCCI class code of the employee. Be sure to complete the full name (last, first, middle), marital status, date hired, state of hire, employee status, and detailed residence address. Include hours worked per day and per week, the average weekly wage, payment information for the day of injury, and the employee's telephone number and number of dependents.
  2. Fill out "Employer Information": Input the name of the employer, employer ID#, SIC code, insured report number, and the complete address of the employer, including a different location address if applicable. Note the carrier/administrator claim number, OSHA log number, and report purpose code.
  3. Proceed to "Carrier / Claims Administrator Information": Detail the name of the claims administrator, carrier federal ID number, and check if it's self-insurance. Provide the policy or self-insured number, insurance carrier, and policy period along with the name of the agent and code number.
  4. Document "Occurrence / Treatment Information": Indicate the date, time of the occurrence, and when the employer was notified. Mark the type of injury or exposure, and fill in codes as required. Include the last work date, time the workday began, the date disability began, part of the body affected, RTW (return to work) date, and if applicable, the date of death.
  5. Describe the accident or exposure in detail, specifying the location if not on the employer’s premises, equipment, materials, or chemicals involved, the specific activity the employee was engaged in, and the work process. Clearly describe how the injury or exposure occurred, including any objects or substances involved.
  6. Input Initial Treatment details: Select the type of initial treatment provided from the options provided. This section helps in understanding the severity of the incident.
  7. Complete "Other Information" including the name of the physician/health care provider, hospital or offsite treatment details, name of any witness, and the telephone number. Also, mention the dates the administrator was notified and the form was prepared, including the preparer's name and title.

After filling out these steps, review the form to ensure all details are accurate and complete. Remember to return the completed form electronically through an approved EDI process, as mentioned at the start of the form instructions. This form plays a vital role in managing worker's compensation claims, and accuracy is key to providing the benefits the employee is entitled to.

Things to Know About Indiana State 34401

What is the Indiana State Form 34401 used for?

This form is utilized for the initial reporting of an employee's work-related injury or illness to the Indiana Worker's Compensation Board. It is a crucial document for initiating the claims process and ensuring the injured or ill employee receives the appropriate compensation and benefits.

How should dates be entered on the Form 34401?

All dates on the Form 34401 should be entered in the month/day/year (MM/DD/YY) format. This consistency is necessary for processing the information accurately and efficiently.

Can the form be submitted electronically?

Yes, the completed Indiana State Form 34401 should be returned electronically via an approved Electronic Data Interchange (EDI) process. This method accelerates the submission and processing of the form.

Who do I contact if I have questions about filling out the form?

For any questions regarding the completion of the form, one should contact the support at (317) 232-3808. This helpline provides the necessary assistance and clarification.

What is the "AGENT NAME AND CODE NUMBER" section for?

This section requires the name and the code number of the insurance agent managing your policy. Knowing your agent's details is essential for further communication or clarification regarding your insurance coverage.

How is the employee's average weekly wage calculated for this form?

The average weekly wage (AVG WG/WK) is determined by totaling the employee’s wages over the latest 52 weeks, including overtime, tips, and other compensations, and then dividing by 52 to find the average.

What should I do if the accident or exposure occurs off the employer's premises?

If the incident occurred away from the employer’s premises, specify the actual address or location in the “DEPARTMENT OR LOCATION WHERE ACCIDENT OR EXPOSURE OCCURRED” section, giving as much detail as possible (for example, “Client’s Office” or “Maintenance Area”).

What if no equipment, materials, or chemicals were involved in the accident or exposure?

If the injury or illness occurred without the involvement of any tools, materials, or chemicals, enter "NA" (Not Applicable) in the relevant section to indicate that nothing was being used, applied, handled, or operated by the employee at the time of the incident.

What does the "REPORT PURPOSE CODE" section represent?

The "REPORT PURPOSE CODE" specifies the reason for the submission of Form 34401. Code "00" stands for the Original First Report of Injury, and Code "02" is used for Updated or Amended First Report, helping in distinguishing the nature of the submission.

Common mistakes

Filling out the Indiana State 34401 form is a critical step in reporting a workplace injury or illness. However, mistakes can complicate or delay the process, affecting the employee’s compensation and recovery period. Here is a detailed overview of eight common mistakes to avoid:

  1. Not completing all sections of the form, specifically leaving out essential information in areas not marked for office use only can lead to significant processing delays. Every field provides vital details for the claim’s review and processing.
  2. Incorrectly entering dates in formats other than MM/DD/YY can lead to confusion and errors in recording the timeline of the incident and subsequent actions, which is crucial for validating the claim.
  3. Failing to return the completed form electronically through an approved EDI process can result in non-compliance with submission guidelines, leading to delays or rejection of the form.
  4. Omitting the agent name and code number, when this information is readily available, can slow down the processing time as it helps in identifying the correct insurance policy related to the claim.
  5. Listing equipment, materials, or chemicals involved inaccurately or not at all can provide incomplete information about the injury's cause, complicating the assessment of the claim.
  6. Miscalculating the average weekly wage or not including all compensable income types can impact the benefits calculation, leading to underpayment or challenges in claim approval.
  7. Forgetting to designate the employee’s status accurately (e.g., full-time, part-time) can create issues in understanding the claimant’s eligibility and the extent of benefits they are entitled to.
  8. Providing vague or incomplete descriptions of how the injury or illness occurred limits the claims administrator's ability to evaluate the claim thoroughly, potentially affecting the outcome of the claim.

When completing the form, it is crucial to be thorough and precise. Simple errors or omissions can not only cause unnecessary delays but may also result in the denial of a claim. Employees and employers must work closely to ensure that the report is accurate and complete before submission. It's also advisable to review each section carefully and consult with a professional if there are any uncertainties about how to properly fill out the form.

Remember, the information provided on this form plays a crucial role in the worker’s compensation process. Taking the time to fill it out correctly is not just a procedural step; it’s a critical component in ensuring the well-being and support of employees who have experienced workplace injuries or illnesses. Accordingly, avoiding these common mistakes can contribute to a smoother, more efficient claims process, ultimately supporting a faster recovery and return to work for the injured or ill employee.

Documents used along the form

Handling worker's compensation claims in Indiana requires more than just the completion of State Form 34401. This document is a key starting point, but it's often accompanied by other paperwork to thoroughly document the incident, manage the claim, and comply with regulatory requirements. Here are four documents commonly used along with the Indiana State 34401 form:

  • Employer’s Report of Injury or Illness: While the State Form 34401 collects initial details, the Employer’s Report provides a comprehensive account of the injury or illness from the employer's perspective, detailing the circumstances and measures taken following the incident.
  • Medical Release Form: This form authorizes the release of medical information related to the worker’s injury or illness to the employer or insurance carrier. It ensures the employer has access to the necessary medical records to process the worker’s compensation claim effectively.
  • Wage Verification Form: To accurately calculate compensation benefits, a Wage Verification Form is used. It details the injured employee's earnings prior to the incident, including hours worked, overtime, and bonuses, to determine the appropriate compensation level.
  • Return to Work Statement: Once an employee is ready to return to work, either in a full or limited capacity, a Return to Work Statement from a healthcare provider specifies the employee’s physical limitations and the type of work they are able to perform. This document helps employers to make necessary accommodations and ensures the employee's safe return to work.

Together, these documents complement the Indiana State 34401 form, creating a detailed and comprehensive claim file that supports both the injured worker and ensures the employer meets regulatory and procedural obligations. Each document plays a crucial role in the processing, evaluation, and resolution of worker's compensation claims, facilitating communication among all parties involved.

Similar forms

The Indiana State 34401 form, formally recognized as the "First Report of Employee Injury, Illness," resembles other forms used across the United States for the reporting of workplace injuries or illnesses. While specific to Indiana, its structure and required information share commonalities with similar documents. These include the collection of basic employee information, details about the injury or illness, the circumstances leading to the event, and initial medical treatment information. This form is a critical piece in the worker's compensation claim process, ensuring timely and accurate reporting to the appropriate state board.

OSHA Form 300 is one example of a document that shares similarities with the Indiana State 34401 form. The OSHA Form 300, or the "Log of Work-Related Injuries and Illnesses," requires employers to record detailed information about work-related injuries and illnesses. Just like the Indiana State 34401 form, it captures data on the nature of the injury or illness, the job title of the affected employee, and where the incident occurred. However, the OSHA Form 300 is part of a federal requirement managed by the Occupational Safety and Health Administration and serves more as a log for recordkeeping rather than a single report for a specific incident.

Another document similar to the Indiana State 34401 form is the WC-1 Employer’s First Report of Injury or Occupational Disease form, used in various states with local variations. This form also seeks detailed information immediately following a workplace injury or disease, mirroring the 34401 form's objective to initiate the worker's compensation process. Both forms require employers to report the injured or ill employee's details, the date, time, and description of the incident, as well as any initial treatment provided. The key difference often lies in state-specific instructions and details required by local worker's compensation boards.

Dos and Don'ts

When completing the Indiana State 34401 form, it's crucial to approach the task with diligence and precision to ensure that the form is filled out correctly and completely. Here are key dos and don'ts that can guide individuals through the process:

Things to DO:
  • Fill in all required fields, except those marked for office use only, to avoid delays in the processing of the form.
  • Use the MM/DD/YY format for all dates to maintain consistency and adhere to the guidelines provided.
  • Return the completed form electronically through an approved EDI process as specified, which streamlines the submission process.
  • Contact the specified number (317) 232-3808 if you have any questions, to ensure accuracy and clarity in your form.
  • Provide detailed descriptions of the accident or exposure, including the sequence of events, to give a clear understanding of the circumstances and cause.
  • Write clearly or type the information to prevent misunderstandings or misinterpretations of your handwriting.
  • Double-check the Social Security number and other personal identifiers for accuracy, as errors can lead to significant complications.
Things NOT to DO:
  • Don't leave any required fields blank; if a section does not apply, enter “NA” to indicate that it's not applicable.
  • Avoid guessing on dates or details; ensure that all information is accurate and verifiable.
  • Do not use any abbreviations unless specified (like in the case of employee status), as they might not be universally understood.
  • Do not fill in the boxes at the top right corner of the form, as these are intended for office use only.
  • Refrain from submitting the form through unauthorized methods; use only approved EDI processes for electronic submission.
  • Avoid neglecting to review the entire form for completion and accuracy before submission to prevent any omissions or errors.
  • Do not provide vague descriptions of how the injury or illness occurred; specificity is crucial for a proper understanding of the event.

Adhering to these guidelines can significantly enhance the effectiveness and efficiency of the form submission process, assisting in ensuring that the necessary actions are taken promptly and accurately for worker's compensation claims in Indiana.

Misconceptions

Misconceptions about the Indiana State 34401 form can lead to errors and delays in processing worker's compensation claims. Here are seven common misconceptions explained:

  • The form is only for injuries, not illnesses: The Indiana State 34401 form is used to report both occupational injuries and illnesses. It is crucial for employers to report any condition that arises due to the work environment or activities.
  • Electronic submission is optional: The instructions clearly state that completed forms should be returned electronically by an approved EDI (Electronic Data Interchange) process. This requirement aims to streamline and expedite the claims process.
  • Personal information is not necessary: The form requires personal information such as the employee's Social Security number and date of birth. This information is crucial for identifying the claimant and pursuing statutory responsibilities. However, disclosure is voluntary, and refusal to provide a Social Security number will not lead to penalties.
  • All sections must be completed by the employer: Certain sections at the top right corner of the form are designated for office use only and should not be filled out by the employer. Misunderstanding which parts of the form to complete can lead to unnecessary delays.
  • Any date format is acceptable: Dates must be entered in the MM/DD/YY format. Using different formats can cause confusion and errors in processing the report.
  • Reporting occupational injuries or illnesses is optional: Indiana law requires employers to report occupational injuries or illnesses using the State Form 344104401. Failure to report can result in a $50 fine, emphasizing the importance of complying with reporting obligations.
  • The form is excessively complex: While the form is comprehensive, it is designed to collect all necessary information to process a worker's compensation claim efficiently. Employers can seek assistance with any questions by calling the provided contact number, making the process manageable.

Understanding and correcting these misconceptions are essential steps in ensuring the accurate and timely processing of worker's compensation claims in Indiana.

Key takeaways

Filling out the Indiana State 34401 form accurately is crucial for the worker's compensation process. Here are some key takeaways to ensure the process goes smoothly:

  • All sections must be completed: It's important to input information into every applicable section of the form, leaving out only the boxes at the top right corner, which are reserved for office use.
  • Date formats matter: Dates should always be filled in using the MM/DD/YY format. This consistency helps avoid confusion and ensures the form is processed without delays.
  • Electronic submission is required: Once completed, the form should be returned electronically through an approved EDI (Electronic Data Interchange) process. Traditional paper forms are not accepted, highlighting the importance of digital literacy in the submission process.
  • Avg Wg/Wk calculation: The claimant's average weekly wage is calculated by summing up the wages of the last 52 weeks, including overtime and tips, and dividing by 52. This figure is pivotal in determining compensation amounts.
  • Immediate and accurate reporting is vital: Employers need to report occupational injuries or illnesses immediately using this form. Delay or failure to report can lead to penalties, including a fine, as mentioned in the form's reminder about potential consequences for non-compliance.

Understanding these aspects of the form can help ensure that it is filled out properly, thereby aiding employees in receiving the correct compensation for workplace injuries or illnesses in a timely manner. Additionally, knowing whom to contact for questions, as indicated on the form, can be incredibly helpful for clarifications, ensuring accurate and efficient completion and submission.

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