Get Form 118 - Cove Risk

Filling out the Form 118 - Cove Risk is an essential process for employers to report medical-only injuries to the appropriate insurance carrier. This guide will provide clear, step-by-step instructions on how to complete the form online, ensuring accuracy and efficiency.

Follow the steps to successfully complete the Form 118 - Cove Risk.

1. Press the ‘Get Form’ button to access the Form 118 and open it for editing.
2. In the first section, enter the employee's name in the format Last, First MI.
3. Provide the employee's home telephone number in the designated field.
4. Enter the employee's social security number, ensuring it is correctly formatted.
5. Select the marital status of the employee by marking either Single or Married.
6. Indicate the number of dependents the employee has.
7. Fill in the date of hire using the MM/DD/YY format.
8. Provide the employee's date of birth also in MM/DD/YY format.
9. Select the employee's sex by marking the appropriate option.
10. Enter the employee's hourly wage.
11. Specify if the employee is a piece or hourly worker.
12. Indicate the average number of hours worked per day.
13. Enter the average number of days worked per week.
14. Provide the average 52-week wage in dollars.
15. Fill in the employer's name.
16. Indicate if the employer is self-insured by selecting Yes or No.
17. Enter the federal tax identification number of the employer.
18. Fill in the employer's address including street, city, state, and zip code.
19. Provide the employer's telephone number.
20. Enter the relevant industry code for the employer.
21. Fill in the name and address of the insurance carrier responsible for this case.
22. Enter the worker's compensation policy number.
23. If applicable, provide the OSHA case file number.
24. Indicate the date of injury in MM/DD/YY format.
25. Specify the time of injury and whether it occurred in the A.M. or P.M.
26. Describe the source of the injury (e.g., machine, tool, substance).
27. Provide the address where the injury occurred.
28. Indicate if the injury occurred on the employer's premises by selecting Yes or No.
29. Enter the employer location code if applicable.
30. Fill in the regular occupation of the employee when injured.
31. Specify the regular occupation when injured.
32. Enter the date the injury was reported in MM/DD/YY format.
33. Indicate to whom the injury was reported.
34. Describe the nature of the injury using terms like burn, fracture, or cut.
35. Provide a description of the injured body part(s).
36. Fill in the name and address of the physician who treated the injury.
37. Enter the name and address of the hospital, if applicable.
38. Describe how the injury occurred.
39. Indicate if the employee has returned to their regular occupation, and provide the date of return if applicable.
40. Fill in the preparer's name in print or type.
41. Indicate the preparer's title.
42. Enter the date the form was prepared in MM/DD/YY format.
43. Provide the preparer's signature.
44. Once completed, users can save changes, download, print, or share the form as needed.

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