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Instructions for completion —
Employer’s Report Of Industrial Injury Form 101
INSTRUCTIONS
When you are notified of a work- (If your company assigns an OSHA case number, please enter this
related injury, the law requires that information in the upper right hand corner of Form 101 where
you report it within 10 days using an
indicated.)
Employer’
Employer ’s Report of Industrial
Injury—Form 101 [§A.R.S. 23- Employee Information: Lines 1 through 7
908(F)]. We recommend filing the Use the worker’s name as it appears on your payroll. Be sure to
report within 24 hours. To avoid completely fill out this section as the information provided is used for
delays that could lead to increased initial claim processing.
costs, this report should be filled out
Employer Information: Lines 8 though 12
accurately and completely. The form
These items identify you to SCF of Arizona and to the Industrial
is to be completed by the employer,
not the employee. Filling out this Commission of Arizona. To ensure proper identification, show your
form does not admit liability for the company name as listed on your workers’ compensation policy.
injury.
alleged injury. Accident Information: Lines 13 through 35
A fatality must be reported by tele- These items detail the accident that caused the injury, including the
phone within eight hours to the Ari- date the injury occurred. Attach a separate sheet if necessary. Lines
zona Division of Occupational Safety 16-18 assist in determining if the claim is a time-loss claim where
& Health (ADOSH) at 602.542.5795 compensation may be due. Line 20 should list the work-class code
and within 24 hours to SCF of Ari- that payroll is being reported under. This assists in proper reserving. If
zona. your company has set up a departmental coding system with SCF of
The original copy of the Form 101 Arizona to separate injuries by department/location, line 22 should
should be mailed to: also be completed.
Industrial Commission of Arizona All facts of the incident should be verified with the injured worker,
P.O. Box 19070 supervisor and all witnesses. If you question the validity of the claim,
Phoenix, AZ 85005-9070 or if alcohol or drugs may be a factor, state your reasons under item
31, or attach a separate sheet of paper indicating the reason for
And a copy to: doubting the validity of the claim. Document whether a drug and
SCF of Arizona
alcohol test was performed and note results if available. All of this
P.O. Box 33069
information assists in determining the validity of an industrial injury.
Phoenix, AZ 85067-3069
Lines 32 through 34 assist in determining possible third party liability
Reports can also be filed by using for possible cost recovery (subrogation).
the following methods:
Wage Information: Lines 36 through 55.
• Contact our Call Center at
Wage information is required on all claims. Wage information is
602.631.2300 or toll free within
Arizona 800.231.1363 needed to establish the amount of compensation benefits and pos-
• Download the Form 101 from the sible future permanent award benefits. The date of hire (line 40)
SCF web site at www.scfaz.com assists in the determination of compensation and in the calculation of
and the average monthly wage. All fields should be completed in full to
• Fax to 602.631.2888 or toll free accurately calculate the injured worker’s average monthly wage. Do
within Arizona at 800.356.4867 not include the wages earned for the date of injury in any of the
• or E-mail to scf101@scfaz.com. earnings totals.
Authorized signature line:
Only the policyholder or authorized representative should sign and
date the Form 101. The injured worker does not sign this form.
See form on reverse side
Visit our web site at www.scfaz.com for additional information.
For instructions see reverse side
S
EMPLOYER’ 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. Arizona
SCF of Arizona
MAIL TO: (CARRIER NAME & ADDRESS) OSHA Case #:
P.O. BOX 33069
Employer must, on this form, notify his insurance carrier of every RECORDABLE INJURY
injury or disease suffered by an employee, fatal or otherwise,
PHOENIX, ARIZONA 85067-3009
which is claimed to arise our of or in the course of employment. 1-800-231-1363 NON-RECORDABLE INJURY
ARIZONA REVISED STATUTES 23-908 & 23-1061 FAX: 1-800-356-4867
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 S
8. EMPLOYER’ NAME 9. POLICY NUMBER 10. NATURE OF BUSINESS (MANUFACTURING, ETC.)
11. OFFICE ADDRESS (NUMBER & STREET) CITY STATE ZIP CODE 12. TELEPHONE
ACCIDENT 13. DATE OF INJURY OR ILLNESS 14. TIME OF EVENT 15. TIME EMPLOYEE BEGAN WORK 16. DATE EMPLOYER NOTIFIED OF INJURY
A.M. P.M. A.M. P.M.
17. LAST DAY OF WORK AFTER INJURY 18. DATE OF RETURN TO WORK S
19. EMPLOYEE’ OCCUPATION (JOB TITLE) WHEN INJURED
20. CLASS CODE ON PAYROLL REPORT S
21. EMPLOYEE’ 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
h p s ;c ;c
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 “ urt,” “ ain,” or sore.” Examples: “ trained back” “ hemical burn, hand” “ arpal 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 EMPERGENCY NAME OF PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL ADDRESS (STREET, CITY, STATE & ZIP CODE)
ROOM?
YES NO
30. WAS EMPLOYEE HOSPITALIZED OVERNIGHT AS IF HOSPITALIZED, HOSPITAL NAME ADDRESS (STREET, CITY, STATE & ZIP CODE)
AN IN-PATIENT?
YES NO
31. IF VALIDITY OF CLAIM IS DOUBTED, STATE REASON
CAUSE OF W ; W ; W
32. WHAT HAPPENED? Tell us how the injury occurred. Examples: “ hen ladder slipped on wet floor, worker fell 20 feet” “ orker was sprayed with chlorine when gasket broke during replacement” “ orker
developed soreness in wrist over time.”
ACCIDENT
c ; c ; r
33. WHAT OBJECT OR SUBSTANCE DIRECTLY HARMED THE EMPLOYEE? Examples: “ oncrete floor” “ hlorine” “ adial arm saw.” If this question does not apply to the incident, leave it blank.
Examples: “ limbing a ladder while carrying
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. c
; s ; d
roofing materials” “ praying chlorine from hand sprayer” “ aily computer key -entry.”
35. IF ANOTHER PERSON NOT IN COMPANY EMPLOY CAUSED ACCIDENT, GIVE NAME AND ADDRESS
S
EMPLOYEE’ 36. WAS WORKER IN YOUR EMPLOY 37. HOURS PER DAY EMPLOYEE WORKED 38. WAS EMPLOYEE ON OVERTIME 39. NUMBER OF DAYS PER WEEK
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
YES NO IF YES, $
EMPLOYMENT?
YES NO
43. NUMBER OF MONTHS EMPLOYMENT S
44. GIVE EMPLOYEE’ 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 PRECEEDING INJURY
(EXAMPLE: IF INJURED APRIL 8, GIVE EARNINGS FROM MARCH 9 THRU APRIL 7) 47. DOES EMPLOYEE CLAIM DEPENDENTS? YES NO
IF EMPLOYEE IS PAID OTHER THAN FIXED WEEKLY 48. IF EMPLOYEE EARNS EXTRA PAY FOR OVERTIME, WHAT IS BASIS OF 49. NUMBER OF HOURS OVERTIME CONSIDERED
IMPORTANT OR MONTHLY SALARY, COMPLETE ITEMS 48 THRU 55 PAYMENT? NORMAL PER 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
$ $ $
AUTHORIZED DATE AUTHORIZED SIGNATURE TITLE
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) ofFederal Privacy Act of
the
s s
1974, because the Commission’ forms, prescribed under the Commission’ 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.
Form ICA 04-0101 (Rev. 7/01) THIS FORM APPROVED BY THE INDUSTRIAL COMMISSION OF ARIZONA FOR CARRIER USE
41-101i 10/2001
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