Get Employer's Report Of Accident Kwc 1101-a - Kansas State ...

This guide provides a step-by-step approach to completing the Employer's Report of Accident KWC 1101-A online. Whether you are familiar with this process or approaching it for the first time, this clear instructional guide will assist you in accurately filling out the necessary information.

Follow the steps to complete the report efficiently.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering the OSHA case or file number if applicable, followed by the federal employer's identification number and employee's date of hire.
3. Input the employer's name and contact information, including the phone number and mailing address. If the location of the accident differs from the mailing address, provide that information as well.
4. Indicate the nature of the business and the corresponding NAICS or S.I.C. code along with the department or division involved.
5. Provide the employee's full name, age, and sex, along with their home address and occupation. Include their Social Security number and the date they were hired.
6. Enter the date and time of the injury, along with the county where the accident occurred. Record the date the employer was informed of the incident.
7. Clarify whether the accident occurred on the employer's premises and provide a detailed description of how the accident occurred and what the employee was doing when injured.
8. State the name of the object or substance that directly caused the injury, and give a comprehensive description of the nature and extent of the injury, indicating the body part affected.
9. Complete the questions regarding hospital admission, date treated, and the attending physician or clinic.
10. Indicate whether the employee has returned to work, whether they are on regular or light duty, and if compensation is currently being paid.
11. Conclude by providing any necessary details regarding the employee's death, if applicable, and list the dependents.
12. Once all fields are completed, save your changes, and choose to download, print, or share the form as needed.

Complete your Employer's Report of Accident KWC 1101-A online to ensure timely processing and compliance.