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The Indiana State Form 34401 is a critical document designed for reporting workplace injuries and illnesses in an efficient and standardized manner. This form serves as the First Report of Injury, and it requires comprehensive details about the injured employee and the circumstances surrounding the incident. Information fields include the contact details of the insurance agent, the nature of the injury, and the specifics of the employee's work status. The claim must specify the equipment or materials involved in the accident, as well as the applicable NCCI class code that identifies the employee's occupation. Other essential data includes the average weekly wage of the injured worker, the date the disability began, and the return-to-work date. Employers must ensure that all sections of the form are populated accurately and completely, as incomplete forms can lead to delays in processing claims. Additionally, the form consists of various purpose codes that categorize the type of report being submitted. Employers should be aware that failure to comply with reporting rules may result in penalties. Thus, understanding and properly completing the Indiana State Form 34401 is vital for both the employer and the employee to facilitate timely access to workers' compensation benefits.

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).

Click for Indiana State 34401 File

File Breakdown

Fact Name Detail
Form Title Indiana Worker’s Compensation First Report of Employee Injury, Illness State Form 34401
Governing Law Indiana Code IC 22-3-4 governs the reporting of workplace injuries.
Submission Format Forms must be completed electronically via an approved EDI process.
Date Format All dates on the form should be entered in MM/DD/YY format.
Contact Information Questions can be addressed by calling (317) 232-3808.
Claim Administrator Enter the name of the entity responsible for administering the claim, such as an insurance carrier or third-party administrator.
Employee Status Options Status can be categorized into several options, including Full-time, Part-time, and Volunteer.
Report Purpose Codes Codes indicate the purpose of the report: 00 for Original, 02 for Updates.
Average Wage Calculation Average weekly wage should include the latest 52 weeks of earnings, divided by 52.
Penalty for Non-compliance A $50 fine may be imposed for failure to report an occupational injury (IC 22-3-4-13).

Guide to Using Indiana State 34401

Completing the Indiana State 34401 form requires attention to detail and accurate information. This form is used to report an employee's injury or illness under worker's compensation. To ensure that all necessary information is included, follow these step-by-step instructions carefully.

  1. Begin by entering the employee's information. Fill in the social security number, date of birth, and sex. Include the employee's name (last, first, middle) and marital status.
  2. Provide the employee’s occupation or job title along with the NCCI class code. This code categorizes the employee's job in terms of risk.
  3. Complete the employee's address including street number and name, city, state, and ZIP code.
  4. Fill in the employee's hiring details. Include the date hired, state of hire, employee status, average hours per day, and average wages per week.
  5. Next, enter the employer's information. This includes the employer's name, ID number, SIC code, and address. Make sure to include the employer's telephone number, as well.
  6. Provide the claims administrator's information including their name, federal ID number, and address. Indicate if this is a self-insurance case.
  7. Fill in the occurrence or treatment information. Note the date and time of the injury or exposure, and whether the employee was notified. Describe the type of injury or exposure.
  8. In the section for how the injury/exposure occurred, detail the sequence of events. Be descriptive; mention if any equipment, materials, or chemicals were involved.
  9. Indicate the part of the body affected by the injury and any necessary codes related to the injury type. For instance, you may need to describe if the injury was a fracture or a contusion.
  10. Detail the initial treatment received. Specify if no medical treatment was given or if minor treatment occurred by the employer or at a hospital.
  11. Conclude by reviewing the form for accuracy. Make sure you included all necessary details and followed the instructions.

Once completed, submit the form electronically using an approved EDI process. For any questions, you can call the designated number provided on the form. Make sure all information is clear and thorough for a smooth processing experience.

Get Answers on Indiana State 34401

What is the Indiana State 34401 Form?

The Indiana State 34401 form is used to report employee injuries or illnesses for worker's compensation purposes. This form provides details about the incident, helping ensure proper handling of the claim.

Who needs to fill out this form?

This form should be filled out by employers when an employee experiences a work-related injury or illness. It's crucial for documenting the event and for the employee to receive appropriate benefits.

How do I complete the Indiana State 34401 Form?

To complete the form, follow these guidelines:

  1. Fill all sections except the boxes in the top right corner, which are for office use only.
  2. Enter dates using the MM/DD/YY format.
  3. Submit the completed form electronically as per the approved EDI process.

What information is required on the form?

You'll need to provide information such as:

  • Employee name and job title
  • Nature of the injury or illness
  • How the injury occurred
  • Medical treatment details
  • Contact information for follow-up

What if there was no medical treatment?

If the employee did not receive any medical treatment, you still need to mark this on the form. Indicate “No Medical Treatment” in the treatment section. It's essential to report this accurately, even if the injury seems minor.

Where do I submit the completed form?

Submit the completed form electronically through an approved EDI process. Ensure that you are following the submission guidelines to avoid any delays in processing the claim.

What happens if the form is not submitted?

If the form is not submitted, there can be penalties. Employers may face fines, such as a $50 fine for failing to report an occupational injury or illness according to Indiana law. Timely submission is important to avoid issues.

Common mistakes

Filling out the Indiana State 34401 form can be a straightforward process, but there are common errors that people often make. The first mistake is leaving required fields blank. Every section of the form is designed to capture critical information about the accident or exposure. Missing details can delay the processing of the claim or lead to unnecessary complications. Consequently, it's important to ensure that all provided areas are completed, leaving only the office-use boxes empty.

Another frequent mistake involves the format of the dates. The form specifically requests that dates be entered in MM/DD/YY format. When users fail to adhere to this standard, it can result in confusion and miscommunication. Always double-check the date entries to make sure they comply with this requirement. Correct formatting is essential for the accurate processing of claims.

Providing inaccurate information about wages is another common error. Claimants should calculate their average weekly wage accurately by totaling the last 52 weeks of earnings and dividing by 52. Failing to include overtime, tips, or other forms of compensation can lead to an underreporting of wages. This may affect benefits received, so it’s crucial to be thorough and precise when reporting earnings.

A further oversight often occurs when describing the circumstances of the injury or illness. Vague or incomplete descriptions can hinder claim evaluations. Claims administrators need detailed accounts that specify what happened during the incident, including actions taken right before the injury and the environment in which it occurred. This comprehensive detail plays a significant role in the accurate assessment of the claim.

Lastly, people occasionally neglect to note the contact information for the claims administrator or the supervisor at the workplace. This information is essential for follow-ups or additional queries related to the claim. Without clear contact details, the claims process can become protracted and cumbersome. Make sure to include this information to facilitate efficient communication and resolution.

Documents used along the form

The Indiana State Form 34401 is crucial for reporting employee injuries and illnesses related to workplace incidents. This form initiates the documentation process necessary for workers' compensation claims. There are several other documents that frequently accompany this form, each serving different aspects of the claims process. Here's a concise overview of these forms and documents:

  • Employee Incident Report: This internal document collects detailed information about the specific incident, including eyewitness accounts and immediate responses to the injury. It helps establish a clear sequence of events that led to the injury.
  • Claim Form: In many cases, a specific claim form needs to be filled out to formally request compensation from the insurance provider. This document typically includes details similar to those in the Indiana State Form 34401 but may request additional financial information.
  • Medical Release Form: This document authorizes medical providers to share the injured employee's medical records with the employer and the claims administrator. It ensures that the claims process is supported by appropriate medical documentation.
  • Return-to-Work (RTW) Agreement: Once the employee is ready to resume work, this agreement outlines the plan for their return, including any necessary accommodations or modified duties based on the recovery progress.
  • First Aid Report: If first aid was administered on site, this document captures the details of treatment provided, ensuring there’s a record of initial care given before any further medical treatment.
  • Witness Statements: Statements from individuals who observed the incident can be important in understanding the context. These narratives may provide insight into workplace conditions at the time of the injury.
  • Workers’ Compensation Claim Acknowledgment Letter: This letter indicates that the workers' compensation insurer has received the claim and provides initial instructions regarding the next steps in the claim process.

These forms and documents work together to create a comprehensive picture of an injury event, ensuring that the affected employee's rights are protected and that the claims process proceeds smoothly. Understanding how each fits into the overall procedure can be key to navigating workplace incidents effectively.

Similar forms

The Indiana State Form 34401 serves as a formal document for reporting employee injuries or illnesses. Other documents that share similar purposes include:

  • First Report of Injury Form: Used in various states, this document also captures essential details about an employee's injury, the circumstances surrounding it, and required administrative information.
  • Worker’s Compensation Claim Form: This form initiates a worker's compensation claim, outlining the injury details and seeking benefits similar to the Indiana State Form 34401.
  • Incident Report: This document records events leading to an injury or accident and includes witness statements, providing context much like the injury occurrence description required on the Indiana form.
  • Insurance Claim Form: Employees use this to claim benefits from their insurance company, reporting similar information regarding the injury as the Indiana State Form 34401 requires.
  • Occupational Health Incident Report: This focuses on health-related incidents at the workplace, detailing exposure to harmful conditions, akin to how the Indiana form addresses the cause of injury or illness.
  • Employee Medical Leave Request: Used when seeking leave due to illness or injury, this form often requires similar information about the employee's job status and related details as the Form 34401.
  • Return to Work Authorization: Similar in that it includes medical documentation about an employee’s ability to return to work, it often references the earlier injury report to ensure continuity of information.

Dos and Don'ts

Things You Should Do:

  • Fill out all sections of the form, except the office use boxes at the top right corner.
  • Enter all dates in the correct format: MM/DD/YY.
  • Provide detailed descriptions of the accident or exposure, including activities and equipment involved.
  • Contact the provided telephone number for any questions or clarification.

Things You Shouldn't Do:

  • Do not leave any relevant sections empty; completeness is important.
  • Avoid using abbreviations or shorthand that may cause confusion.
  • Don't forget to indicate your employee's status correctly.
  • Refrain from submitting the form via an unapproved method; use the established EDI process.

Misconceptions

Misconceptions often arise about the Indiana State 34401 form. Here are eight common misunderstandings and their clarifications:

  • The form is optional for employers. Some think submitting the form is not mandatory. In reality, it is a requirement for reporting work-related injuries or illnesses.
  • Only serious injuries need to be reported. Many believe that only major injuries should be documented. However, all injuries or exposures, regardless of perceived severity, must be reported.
  • The form can be filled out later. There is a misconception that the form can be submitted at any time after an incident. The form should be completed and submitted promptly after an injury or exposure occurs.
  • All information is for internal use only. Some individuals think the details are only for employer records. This information can also be used by state agencies for regulatory purposes.
  • Time format doesn't matter. Some may not pay attention to the required date format. It is crucial to enter all dates in the MM/DD/YY format as specified on the form.
  • Injuries occurring off the premises don’t need a report. Many think injuries that happen outside the workplace don’t require documentation. This is inaccurate; the form must be filled out for injuries related to work, regardless of location.
  • Employers can leave sections blank. There is a belief that incomplete forms are acceptable. Every section should be filled out with relevant details to ensure accurate reporting.
  • The form is just a formality. Some individuals view this reporting as a mere formality. However, it plays a vital role in tracking workplace safety and protecting workers' rights.

Key takeaways

Using the Indiana State Form 34401, often known as the First Report of Employee Injury or Illness, requires careful attention to detail. Here are six key takeaways to help you navigate the process effectively:

  • Complete All Required Fields: Ensure that you fill in all areas of the form, except for the office use only boxes located at the top right corner. Missing information could delay processing.
  • Detail the Incident: Provide a clear description of how the injury or illness occurred. It's important to include any equipment or chemicals the employee was using, as well as specifics about the location and nature of the work involved.
  • Average Weekly Wage Calculation: When entering the average weekly wage, include all earnings from the last 52 weeks. This should encompass overtime, tips, and any additional compensation.
  • Return Date Information: If the employee has returned to work, clearly state the Return to Work Date. This helps in understanding the duration of the injury and facilitates the claims process.
  • Submit Electronically: After completing the form, it must be returned electronically through an approved EDI process. Making sure you follow this step can prevent any issues or delays in processing the claim.
  • Seek Assistance If Needed: If you have questions while filling out the form, do not hesitate to reach out to the contact number provided—(317) 232-3808. Getting clarity before submission ensures accuracy.