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The Indiana State 34401 form plays a crucial role in the reporting and processing of workplace injuries and illnesses within the state. This form serves as the First Report of Injury and is essential for employers to accurately document incidents that occur in the workplace. Completion of the form requires careful attention to detail, as it encompasses a range of information, including employee details, the specifics of the accident or exposure, and treatment information. Fields like the employee's average weekly wage, occupation, and the nature of the injury must be filled in precisely to ensure a smooth claims process. It also asks for information regarding the claims administrator overseeing the report, ensuring that communication lines remain open for any follow-up. Employers are instructed to return the completed form electronically and to utilize a designated EDI process for submission. This systematic approach not only streamlines the claims process but also helps maintain accurate records, which can be beneficial for both the employee and the employer in addressing the effects of workplace incidents.

Indiana State 34401 Example

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

 

 

 

 

 

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

Telephone number

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

Telephone number

 

 

 

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

 

Telephone number

Date administrator notified

 

 

 

 

 

 

Date prepared

Name of preparer

 

Title

 

Telephone number

 

 

 

 

 

 

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).

Get Indiana State 34401 PDF Form

Form Characteristics

Fact Name Description
Form Purpose The Indiana State 34401 form, also known as the First Report of Employee Injury or Illness, is designed for reporting workplace injuries or illnesses to facilitate workers' compensation claims.
Filing Format It must be completed electronically and returned via an approved EDI process. Paper submissions are not accepted.
Date Format All dates on the form need to be entered in the MM/DD/YY format to ensure proper processing.
Contact Information The form requires contact details such as the name and phone number of an individual at the employer's premises who can provide additional information about the claim.
Legal Governing Law This form is governed by Indiana Code IC 22-3-4-13, which outlines the requirements and penalties for failing to report occupational injuries.
Agent Information Claimants must enter the name and code number of their insurance agent, information typically found on the insurance policy.

Guidelines on Utilizing Indiana State 34401

Completing the Indiana State 34401 form requires careful attention to detail to ensure all necessary information is accurately reported. After filling out this form, it will be submitted electronically for processing. Below is a step-by-step guide to assist with the completion.

  1. Obtain the form: Download the Indiana State 34401 form from the official website.
  2. Fill in Employee Information: Enter the employee’s name (last, first, middle), Social Security number, date of birth, and sex. Include occupation/job title, NCCI class code, marital status, and date hired.
  3. Provide Address: Fill in the complete address of the employee, including number, street, city, state, and ZIP code.
  4. Employee Status: Indicate if the employee is full-time, part-time, or any other applicable status.
  5. Work Details: Specify average wage per week, hours per day, and days per week the employee worked.
  6. Employer Information: Complete the employer's information, including name, employer ID, SIC code, and address.
  7. Claims Administrator Details: Enter the name of the claims administrator, including their address and telephone number.
  8. Occurrence/Treatment Section: Record the date and time of occurrence, date employer was notified, and type of injury or exposure.
  9. Describe What Happened: Provide a detailed explanation of how the injury or exposure occurred, listing any equipment, materials, or chemicals involved.
  10. Additional Details: Fill in the return to work date, part of the body affected, and whether medical treatment was required.
  11. Contact Information: List the name and contact number of the person to reach for further information.
  12. Final Review: Ensure that all information is complete, accurate, and formatted correctly in MM/DD/YY where necessary.
  13. Submit the Form: Return the completed form electronically by an approved EDI process as instructed.

What You Should Know About This Form

What is the purpose of the Indiana State 34401 form?

The Indiana State 34401 form serves as the First Report of Employee Injury or Illness. It is primarily used to document workplace injuries or illnesses that an employee may experience. By filling out this form, employers provide essential information to the Indiana Worker’s Compensation Board, which facilitates the assessment and potential compensation related to the injury or illness. Accurate reporting ensures that both employers and employees adhere to state regulations regarding workplace safety and worker rights.

How should the information be entered on the form?

When completing the Indiana State 34401 form, it is crucial to provide complete and accurate information in all relevant sections. Utilize the MM/DD/YY format for all dates. Avoid filling out the boxes at the top right corner, as those are designated for office use only. It is advisable to type or print the information neatly in ink. All provided details—including the employee’s and employer’s information, descriptions of the injury, and relevant dates—must be clear and precise to prevent any processing delays.

Who should be contacted if there are questions about the form?

If questions arise while completing the Indiana State 34401 form, it is recommended to contact the Indiana Worker’s Compensation Board at (317) 232-3808. This resource can provide clarification on form instructions, definitions, or specific requirements necessary for completing the submission. Seeking help ensures that the form is filled out correctly and submitted without issues, which is vital for efficient processing.

What information is needed about the injured employee?

The form requires various details about the injured employee, including their name, date of birth, Social Security number, occupation, average weekly wage, and status (such as full-time or part-time). Additionally, it asks for contact information and other relevant identifiers. All these pieces of information help establish the context of the injury and provide a clear picture of the employee’s background and circumstances surrounding the incident.

What happens if the form is not completed or submitted correctly?

Failure to accurately complete or submit the Indiana State 34401 form can result in delays regarding the processing of the claim. An employer's neglect in reporting an occupational injury or illness may also lead to financial penalties, including a potential $50 fine. Ensuring that all required fields are filled out accurately and completely not only adheres to legal obligations but also protects the rights of employees seeking compensation for their injuries.

Common mistakes

Completing the Indiana State Form 34401 can be straightforward, but many individuals make common mistakes that could delay processing. One of the first mistakes often made is leaving sections blank. It's important to fill out all areas requested, excluding the boxes designated for office use. Not providing complete information could result in questions or further delays.

Another frequent error involves the format of dates. The form specifically requires dates to be entered in MM/DD/YY format. Incorrect formatting, such as writing out the month or using a different date format, can lead to misunderstandings and complications during processing.

Many people fail to provide a clear description of how the injury or exposure occurred. When detailing the sequence of events, it’s best to be specific. Using vague language may lead to confusion regarding the circumstances of the incident. Provide details about the actions that led to the injury or exposure, including any surfaces or objects involved.

The average weekly wage (AVG WG/WK) section often causes problems too. It should reflect a correct calculation of the income from the past 52 weeks, including overtime and tips. Rounding figures or providing estimates can result in inaccuracies, so be diligent in providing an exact calculation.

Omitting the employee status is another issue that arises. Accurately indicating whether the employee is full-time, part-time, or in another status is crucial. Mislabeling the employee’s work status can influence compensation decisions and eligibility.

Individuals might overlook the necessity of including the claims administrator’s information. Entering the relevant details helps speed up communication and processing. Ensure that the name, telephone number, and other required details of the claims administrator are accurately provided.

Additionally, some make the mistake of neglecting the part of the body affected by the injury. Providing accurate and specific information about the impacted area ensures that the claim is properly categorized and processed. It creates a clearer picture of the incident and its consequences.

Another common oversight is failing to indicate the return to work date (RTW DATE). This date is critical in determining the duration of any disability benefits. Without it, the processing timeline can be affected and could extend the time needed for the injured employee to return to work.

Finally, miscommunicating or misunderstanding the treatment and medication received can lead to complications. Be clear about whether medical treatment was provided, detailing the nature and extent of that care. This clarity can significantly affect claims processing and resolution times.

Documents used along the form

The Indiana State Form 34401 is crucial for reporting workplace injuries or illnesses. However, it is often accompanied by some additional forms and documents that play a significant role in the claims process. Understanding these documents can streamline communication and ensure compliance with state regulations.

  • Indiana Worker’s Compensation Fee Schedule: This document outlines the fees that employers must pay for medical services related to employee injuries. It helps to clarify expected costs for treatments and ensures that both employees and employers understand what can be covered under worker’s compensation.
  • Employer's Report of Injury: Often required by insurance companies, this report provides further details about the workplace accident. It includes information about the circumstances surrounding the injury, witness statements, and additional context that may be relevant to the claims process.
  • Return-to-Work Authorization: This document is signed by a healthcare provider to confirm that an employee is fit to return to work following an injury. It ensures that employers are aware of any limitations the employee may have as they transition back into their role.
  • First Report of Injury Checklists: These checklists are often used by HR and management to ensure all necessary information is gathered and submitted properly. They serve as a guide during the reporting process, reducing the risk of missing vital details.

Being familiar with these forms can greatly enhance the efficiency of the claims process. Ensure all relevant documents are completed accurately and submitted promptly to avoid any unnecessary delays or complications.

Similar forms

  • Workers' Compensation Claim Form: Like the Indiana State 34401 form, this document collects detailed information about an employee's injury or illness for compensation purposes, including specifics about the incident and employee details.
  • First Report of Injury Form: This form serves a similar purpose, serving as the initial notification of a workplace incident to the relevant authorities. Information such as the employee's name and the circumstances of the injury are captured.
  • OSHA Incident Report: The OSHA Incident Report also documents workplace injuries. It focuses more on safety regulations and may require details about how safety protocols were followed, similar to the details sought in the Indiana form.
  • Employer's Report of Injury or Illness: This form, often required by various state workers' compensation boards, parallels the Indiana form in documenting the injury or illness's specifics, including employee and employer information.
  • Employee Injury Report: Used internally by many organizations, this report captures essential details about workplace injuries. It is similar in its goal of thorough record-keeping but may focus on organizational procedures.
  • Return-to-Work Form: This document confirms an employee's readiness to return after an injury, detailing when the employee is cleared to resume duties, a process that aligns with the Indiana form's return-to-work date requirements.
  • Incident Investigation Report: Used post-accident to analyze the circumstances, this report collects data and findings about the cause of the incident. It complements the Indiana form by providing a deeper investigation into the accident.
  • Medical Treatment Release Form: This document allows healthcare providers to share the injured employee’s medical information with the employer, just like the Indiana form requires input about any medical care received.

Dos and Don'ts

When filling out the Indiana State 34401 form, it is essential to approach the task with care and attention to detail. Your accuracy can significantly impact the processing of the claim. Below is a list of things you should and shouldn't do:

  • Do: Enter information into all applicable sections of the form.
  • Do: Use the MM/DD/YY format for all dates.
  • Do: Be specific when describing the accident location and sequence of events leading to the injury.
  • Do: Include the average weekly wage calculated from the last 52 weeks.
  • Do: Return the completed form electronically via an approved EDI process.
  • Don't: Skip the boxes marked for office use only at the top right corner of the form.
  • Don't: Leave sections blank unless they are not applicable. In such cases, indicate "NA."
  • Don't: Use abbreviations that are not specified in the form instructions.
  • Don't: Forget to provide emergency contact information or the details of the claims administrator.
  • Don't: Delay submitting the form, as this may result in penalties or complications in processing the claim.

Misconceptions

The Indiana State Form 34401, commonly known as the First Report of Employee Injury or Illness, often faces misunderstandings. Here are some clarifications regarding common misconceptions:

  • It is only for severe injuries. Many believe this form is necessary only for serious injuries. However, it is also required for minor injuries and illnesses that happen at work.
  • Only employers need to fill it out. Some think the responsibility only lies with the employer, but employees need to provide accurate information as well.
  • It can be submitted in any format. Contrary to this belief, the completed form must be returned electronically via an approved EDI process, not through paper mail or in person.
  • Dates can be entered in any format. A common misconception is that any date format is acceptable, but all dates must be entered in MM/DD/YY format as specified in the instructions.
  • Injury descriptions do not need to be detailed. Some people think that brief accounts suffice. In fact, a comprehensive description of how the injury occurred is critical for processing claims effectively.
  • Only full-time employees are covered. There’s a belief that only full-time workers can report injuries on this form. However, employees of all statuses, including part-time and seasonal workers, can report injuries.
  • All sections must be completed. While it may seem like every section requires an entry, it is acceptable to enter “NA” where applicable, particularly if certain information does not apply.
  • Submitting on time is optional. Finally, some think that timely submission is flexible. However, failure to report within the required time frame can lead to legal penalties for the employer.

Understanding these misconceptions can help streamline the claims process and ensure compliance with state requirements.

Key takeaways

Filling out the Indiana State Form 34401 is an important task that requires attention to detail. Here are some key points to consider:

  • Complete All Sections: Ensure all parts of the form are filled out, except the office use boxes at the top right corner.
  • Use Proper Date Format: Enter all dates in the MM/DD/YY format to avoid confusion.
  • Electronic Submission: The completed form should be returned electronically through an approved EDI process.
  • Include Relevant Information: Provide detailed descriptions of the injury, including the specific activity the employee was engaged in at the time.
  • Accurate Wage Calculation: The average weekly wage must be calculated by totaling the last 52 weeks of earnings, ensuring all income sources are included.
  • Document Location and Department: Be specific about where the accident or exposure occurred, including any relevant locations outside of the employer’s premises.
  • Contact Information: Include the name and phone number of a contact person at the employer’s site for follow-up questions regarding the injury or illness.

Understanding these takeaways can help ensure that the form is filled out accurately and completely, facilitating a smoother claims process.

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