Employee Injury and Occupational Illness Investigation Report

When an employee notifies a supervisor that an injury has occurred, it is your department's responsibility to obtain all pertinent information needed for completion of the injury report.  Fax or hand carry this information immediately to Kathy Nord, Human Resources; fax number 3464.  If the injury occurs during the second or third shift or on the weekend, the injury must be reported at the beginning of the next working day.  A delay in reporting an injury has the potential for denial of coverage by the Workers' Compensation Branch.

Workers Comp First Report of Injury or Illness Form (IA-1) - All questions beginning with the section entitled "Employee/Wage" must be answered except those marked N/A.  All questions relating to the accident must have detailed answers.  Under "Initial Treatment" please circle the correct number.  Minor Clinic Hospital is the same as a doctor's office visit.

Also, note that the injured employee MUST sign the fraudulent claim/state information sheet.  The employee's signature certifies that the employee has read the paragraph about Kentucky law and understands that filing a fraudulent claim is a crime.

It is very important that the above information and other related information (medical bills, disability statements, doctors' reports, etc.) be submitted quickly to avoid denial of workers' compensation benefits.

We appreciate your assistance in helping us process workers' compensation claims.  If you have any questions concerning these procedures or forms, please call Kathy Nord at 2146 or Robbie Marine at 2158.