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Get Form Ia 1
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How to fill out the Form Ia 1 online
Filling out the Form Ia 1 online may seem challenging, but this guide is here to help you navigate each section confidently. This form is crucial for reporting injuries or illnesses in the workplace, ensuring that all necessary details are captured accurately.
Follow the steps to complete the Form Ia 1 accurately.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin with filling in the 'Carrier/Administrator Claim Number' and 'Report Purpose Code.' Make sure to enter the correct jurisdiction and claim number details.
- Provide the 'Insured Report Number' and the employer's full name and address, including zip code. Ensure to list the 'Location No.' and 'General SIC Code' accurately.
- Fill in the employer’s Federal Employer Identification Number (FEIN), and their location address if it differs from the main address. Also, include a contact phone number.
- Input policy period dates, along with the name, address, and phone number of the claims carrier or administrator. Check the box if self-insured.
- Complete the employee's legal name (last, first, middle), date of birth, social security number, date hired, and state of hire. Add gender and marital status options.
- Fill in the employee's occupation/job title, address, employment status, number of dependents, and NCCI class code.
- Record the employee's wage rate and detail their work schedule, including hours worked per day. Indicate if full pay continued for the injury date.
- Document the date of injury or illness, time occurred, last work date, and dates when the employer was notified and disability began.
- Provide details about the employer's contact, nature of the injury, affected body part, and whether the injury occurred on the employer's premises.
- Describe the incident, including any objects or substances involved, and note whether safety equipment was provided and used.
- Indicate the type of initial treatment received, and detail the care provider's information along with any witnesses to the accident.
- Finalize by entering the date the administrator was notified, the date the form was prepared, and the preparer's contact details.
- Review the form for accuracy, then save your changes. Depending on your needs, you can download, print, or share the completed form.
Complete your documents online to ensure a streamlined process.
The primary difference between a CA-1 and a CA-2 form lies in the nature of the injury. A CA-1 is used for traumatic injuries that occur suddenly, while a CA-2 is for occupational diseases or injuries that develop over time. Understanding this distinction is vital for filing the correct claims and receiving benefits. US Legal Forms offers resources to help clarify these differences and assist you with Form IA 1.
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