Get Ut 122e 2019-2026

This guide provides a clear and supportive approach to filling out the UT 122E form online. By following the outlined steps, users can efficiently complete the necessary requirements for reporting an injury or illness in the workplace.

Follow the steps to successfully complete the UT 122E form.

1. Press the ‘Get Form’ button to access the UT 122E form online.
2. Begin with the 'Injured Worker Information' section. Enter the full name, phone number, and address of the injured worker. Ensure accuracy when filling in the social security number, date of birth, and marital status.
3. Complete the 'Occupation / Job Title,' 'Date Hired,' and 'Employment Status' fields. List the number of dependents and enter the wage, along with the corresponding wage period (daily, weekly, or monthly). Indicate if full pay was provided for the day of the injury.
4. Move on to the 'Employer Information' section. Fill in the business name, contact information, and the mailing and employment addresses. Provide the employer's FEIN.
5. In the 'Insurance Information' part, specify the insurance carrier, contact details, and policy or self-insured number, along with the policy period.
6. Proceed to the 'Occurrence/Treatment' section. Enter the date and time of the injury, the date the employer was notified, and all relevant details regarding the nature, body part affected, and cause of the injury.
7. Fill in the last day worked, the date the disability began, the return to work date, and if applicable, the date of death and when the administrator was notified. Mark if the injury resulted in a fatality.
8. Provide the address of occurrence and details of the treating physician and their contact information. Indicate whether the worker received medical treatment and detail any witnesses involved.
9. Ensure that all fields are completed without any blanks. After reviewing the form, save your changes and opt to download, print, or share the document as needed.

Complete the UT 122E form online today to ensure timely processing of workplace injuries.