The Indiana State 34401 form is a crucial document used to report employee injuries and illnesses for workers' compensation purposes. It captures essential information about the incident, including details about the employee, the nature of the injury, and the circumstances surrounding the event. Completing this form accurately is vital for ensuring that claims are processed efficiently and effectively.
To get started, fill out the form by clicking the button below.
When completing the Indiana State 34401 form, several additional documents may be necessary to ensure a comprehensive understanding of the incident and the related claims. Each of these documents serves a specific purpose and can help streamline the claims process.
Gathering these documents can significantly aid in the claims process, ensuring that all relevant information is available for review. This thorough approach helps protect the rights of the employee while providing the employer with necessary documentation for compliance and accountability.
Leaving Sections Blank: Many individuals forget to fill out all the required areas of the form. It is crucial to complete every section, except for the boxes designated for office use at the top right corner.
Incorrect Date Format: Dates must be entered in the MM/DD/YY format. Using a different format can lead to confusion and delays in processing the report.
Not Providing Detailed Descriptions: When describing how the injury or illness occurred, vague explanations can hinder the understanding of the incident. Specific details about the sequence of events are necessary for accurate reporting.
Omitting Employee Status: Failing to indicate the employee’s work status can lead to complications. It is important to choose from the provided options, such as Full-time or Part-time, and to abbreviate if necessary.
Incorrectly Calculating Average Weekly Wage: The average weekly wage should be calculated by totaling the last 52 weeks of earnings, including overtime and tips, and then dividing by 52. Errors in this calculation can affect compensation.
Inaccurate Contact Information: Providing incorrect contact names or telephone numbers can make it difficult for claims administrators to reach the right person for additional information. This can delay the processing of the claim.
Not Using the Correct Report Purpose Code: It is essential to select the correct report purpose code. The options are 00 for the original report and 02 for updates or amendments. Using the wrong code can complicate the claim's status.
When filling out the Indiana State 34401 form, it is essential to follow specific guidelines to ensure accuracy and compliance. Here are some key takeaways:
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INSTRUCTIONS
General Instructions:
1.Please enter information into all of the areas of the First Report form, except the boxes at the top right corner of the form which is for office use only.
2.Enter all dates in MM/DD/YY format.
3.Please return completed form electronically by an approved EDI process.
4.For answers to questions, please call (317) 232-3808.
Definitions:
AGENT NAME AND CODE NUMBER: Enter the name of your insurance agent and his / her code number if known. This information can be found on your insurance policy.
ALL EQUIPMENT, MATERIALS OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR EXPOSURE OCCURRED: List anything the employee was using, applying, handling or operating when the injury or exposure occurred. If the injury involves a fall, indicate any surfaces and / or objects the claimant fell on and where they fell from. Enter “NA” if no equipment, materials or chemicals were being used (e.g. Acetylene cutting torch, metal plate, etc.).
AVG WG/WK: Claimant’s average weekly wage, calculated by totaling the latest 52 weeks of wages (including overtime, tips, etc.) and dividing by 52.
CLAIMS ADMINISTRATOR: Enter the name of the carrier, third-party administrator, state fund, or self-insured responsible for administering the claim.
CONTACT NAME / TELEPHONE NUMBER: Enter the name of the individual at the employer’s premises to be contacted for additional information (i.e. Supervisor, HR Person, Nurse, etc.)
DATE DISABILITY BEGAN: The first day on which the claimant originally lost time from work due to the occupational injury or disease or as otherwised deigned by statute.
DEPARTMENT OR LOCATION WHERE ACCIDENT OR EXPOSURE OCCURRED: If the accident or exposure did not occur on the employer’s premises, enter address or location. Be specific (e.g. Maintenance, Client’s Office, Cafeteria, etc.).
EMPLOYEE STATUS: Indicate the employee’s work status from the following choices: Full-time, Part-time, Apprentice Full-time, Apprentice Part-time, Volunteer, Seasonal Worker, Piece Worker, On-Strike, Disabled, Retired, Not Employed or Unknown (you may also abbreviate the above as: (FT, PT, AFT, APT, VO, SW, PW, OS, DI, RE, NE, or UK).
HOW INJURY / ILLNESS OCCURRED: Describe the sequence of events leading to the injury or exposure (e.g. Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, he brushed against the hot metal; Worker stepped to the edge of the scaffolding, lost balance and fell six feet to the concrete floor. The worker’s right wrist was broken in the fall).
NCCI CLASS CODE: A four-digit code classifying the occupation of the claimant.
OCCUPATION / JOB TITLE: Enter the primary occupation of the claimant at the time of the accident or exposure.
PART OF BODY AFFECTED: Indicate the part of body affected by the injury / illness (e.g. Right forearm, Low Back, etc.)
REPORT PURPOSE CODE: 00 = Original First Report of Injury; 02 = Updated or Amended First Report.
RTW DATE (Return to Work Date): Enter the date following the most recent disability period on which the employee returned to work.
SIC CODE: This is the code which represents the nature of the employer’s business which is contained in the Standard Industrial Classification Manual published by the Federal Office of Management and Budget.
SPECIFIC ACTIVITY EMPLOYEE ENGAGED IN DURING ACCIDENT / EXPOSURE: Describe the specific activity the employee was engaged in during the accident or exposure (e.g. Cutting metal plate for flooring, sanding ceiling woodwork in preparation for painting).
TYPE OF INJURY / ILLNESS: Briefly describe the nature of the injury or illness (e.g. Contusion, Laceration, Fracture, etc.)
WORK PROCESS THE EMPLOYEE WAS ENGAGED IN DURING ACCIDENT / EXPOSURE: Enter “NA” if employee was not engaged
in a work process, such as if walking down the hallway (e.g. Building maintenance).
INDIANA WORKER’S COMPENSATION
FIRST REPORT OF EMPLOYEE INJURY, ILLNESS
State Form 34401 (R10 / 1-02)
FOR WORKER’S COMPENSATION BOARD USE ONLY
Jurisdiction
Jurisdiction claim number
Process date
Please return completed form electronically by an approved EDI process.
PLEASE TYPE or PRINT IN INK
NOTE: Your Social Security number is being requested by this state agency in order to pursue its statutory responsibilities. Disclosure is voluntary and you will not be penalized for refusal.
EMPLOYEE INFORMATION
Social Security number
Date of birth
Sex
Occupation / Job title
NCCI class code
Male
Female
Unknown
Name (last, first, middle)
Marital status
Date hired
State of hire
Employee status
Unmarried
Address (number and street, city, state, ZIP code)
Married
Hrs / Day
Days / Wk
Avg Wg / Wk
Paid Day of Injury
Separated
Salary Continued
Wage
Per
Hour
Day
Month
Telephone number (include area
Number of dependents
$
Week
Year
Other
EMPLOYER INFORMATION
Name of employer
Employer ID#
SIC code
Insured report number
Address of employer (number and street, city, state, ZIP code)
Location number
Employer’s location address (if different)
Telephone number
Carrier / Administrator claim number
OSHA log number
Report purpose code
Actual location of accident / exposure (if not on employer’s premises)
CARRIER / CLAIMS ADMINISTRATOR INFORMATION
Name of claims administrator
Carrier federal ID number
Check if appropriate
Self Insurance
Address of claims administrator (number and street, city, state, ZIP code)
Policy / Self-insured number
Insurance Carrier
Third Party Admin.
Policy period
From
To
Name of agent
Code number
OCCURRENCE / TREATMENT INFORMATION
Date of Inj./ Exp.
Time of occurrence
AM PM
Date employer notified
Type of injury / exposure
Type code
Cannot be determined
Last work date
Time workday began
Date disability began
Part of body
Part code
RTW date
Date of death
Injury / Exposure occurred
Yes
Name of contact
on employer’s premises?
No
Department or location where accident / exposure occurred
All equipment, materials, or chemicals involved in accident
Specific activity engaged in during accident / exposure
Work process employee engaged in during accident / exposure
How injury / exposure occurred. Describe the sequence of events and include any relevant objects or substances.
Cause of injury code
Name of physician / health care provider
Hospital or offsite treatment (name and address)
Name of witness
Date administrator notified
Date prepared
Name of preparer
Title
INITIAL TREATMENT
No Medical Treatment
Minor: By Employer
Minor: Clinic / Hospital
Emergency Care
Hospitalized > 24 Hours
Future Major Medical / Lost
Time Anticipated
An employer’s failure to report an occupational injury or illness may result in a $50 fine (IC 22-3-4-13).