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1. FederalEmployer'sIdenticationNumber_________________________________________ Dateofhire __________________
2. Nameofemployer____________________________________________________________Phone______________________
3. Mailingaddress__________________________________________________________________________________________________________
Street City State ZIP
4. Location,ifdifferentfrommailingaddress______________________________________________________________________________________
Street City State ZIP
5. Natureofbusiness_________________________________ NAICSorS.I.C.Code___________Dept.ordivision___________________________
6. Nameofemployee_________________________________________________________________________________Age______Sex______
First Middle Last
7. Homeaddress ________________________________________________
________
___________________________________
__________
_____
Street City State ZIP
Birth Employee's Home
8. SSN_____________________date________________ occupation________________________________ phone_________________________
9. Dateofinjuryoroccupationaldisease__________________Timeofinjury_________a.m./p.m.
Datereportedtoemployer__________________Datedisabilitybegan__________________Grossaverageweeklywage$_________________
10. Placeofaccidentorlastexposure ____________________________________________________________________________________________
City County State
11. Wasaccidentorlastexposureonemployer'spremises?
c
YES
c
NO
12. Howdidaccidentoccur? ___________________________________________________________________________________________________
________________________________________________________________________________________________________________________
13. Whatwasemployeedoingwheninjured?______________________________________________________________________________________
________________________________________________________________________________________________________________________
14. Namesubstanceorobjectthatdirectlycausedinjury
*
____________________________________________________________________________
________________________________________________________________________________________________________________________
15. Describeindetailnatureandextentofinjury,indicatepartofbodyinvolved
*
___________________________________________________________
________________________________________________________________________________________________________________________
16. Wasworkeradmittedtohospital?
c
YES
c
NODate__________________Treatedbyemergencyroomonly?
c
YES
c
NO
Hospitalnameandaddress _________________________________________________________________________________________________
17. Nameandaddressofattendingphysicianorclinic _______________________________________________________________________________
________________________________________________________________________________________________________________________
18. Hasemployeereturnedtoregularduty?
c
YES
c
NOLightduty?
c
YES
c
NODate_________________________
19. Iscompensationnowbeingpaid?
c
YES
c
NODaterst/initialpayment____________________
20.Weeklycompensationrate$____________________Isfurthermedicalaidneeded?
c
YES
c
NO
c
UNKNOWN
21. Didemployeedie?
c
YES
c
NOIfYES,givedateofdeath___________________(Fileamendedreportwithin28daysifdeathsubsequentlyoccurs.)
22. Name(s)andaddress(es)ofdependents(deathcasesonly)________________________________________________________________________
________________________________________________________________________________________________________________________
23. Insurancecarrierandthirdpartyadministrator___________________________________________________________________________________
Address ________________________________________________________________________________Phone__________________________
Street City State ZIP
Policynumber____________________________________________Nameofagent___________________________________________________
Claimnumber___________________________________ Nameofclaimrepresentative________________________________________________
24. Dateofreport_________________Completedby______________________________________ Title_____________________________________
OSHA Case or File Number ______________________________
KANSASDEPARTMENTOFLABOR
www.dol.ks.gov
ACCIDENT REPORT
K-WC1101-A(Rev.10-13)
Page1of2
Thereisa$250penaltyforrepeatedfailuretoleaccidentreportswithin28daysofthedatethe
employerisinformedoftheaccident.Submission does not constitute admission of liability.
– SEE INSTRUCTIONS ON PAGE 2 –
Sendthiscompletedformtoyour
insurer,thirdpartyadministrator
orpoolassociationforsubmission
electronicallytotheDivisionof
WorkersCompensation.
Direct questions or comments to:
Tollfree(800)332-0353
FOR
OFFICE
USE
CAUSE
NATURE
SEVERITY
COUNTY
SOURCE
MEMBER
0- NOTIMELOST
1- TIMELOST
2- MEDICAL
3- FATAL
()
()
()
Instructions
Youmustanswereveryquestion;failuretoanswerallquestionsmaycausethereporttobereturnedtothe
employer.Returnedaccidentreportsmaycauseadelayofbenetstotheinjuredemployeesandcouldsubjectthe
employertones.
Theemployermustsendthisaccidentreporttoitsinsurancecarrier,thirdpartyadministratororpoolassociation
forelectronicsubmissiontotheKansasDepartmentofLaborDivisionofWorkersCompensation.
*Instructions for Questions 14 and 15
14:Nametheobjectorsubstancewhichdirectlyinjuredtheemployee.Example:machineorobjectemployee
struckorstruckemployee;vapororpoisonemployeeinhaledorswallowed;chemicalsorradiationwhich
irritatedemployee'sskin;ifhernia,theobjectemployeewasliftingorpulling;etc.
15:Beasspecicaspossibleindicatingallthatisknownabouttheinjury.Namethepartofbodyinjured.
Denition of an Incapacitating Injury
TheWorkers’CompensationActsetsforthastricttimeframeforlingaccidentreportswiththedivision.The
controllingstatuteisK.S.A.44-557(a),whichreadsasfollows:
(a)itisherebymadethedutyofeveryemployertomakeorcausetobemadeareporttothe
directorofanyaccident,orclaimedorallegedaccident,toanyemployeewhichoccursinthe
courseoftheemployee’semploymentandofwhichtheemployerortheemployer’ssupervisor
hasknowledge,whichreportshallbemadeuponaformtobepreparedbythedirector,within28
days,afterthereceiptofsuchknowledge,ifthepersonalinjurieswhicharesustainedbysuch
accidentsaresufcientwhollyorpartiallytoincapacitatethepersoninjuredfromlabororservice
formorethantheremainderoftheday,shiftorturnonwhichsuchinjuriesweresustained.
Accidentreportsarenotrequiredforeverywork-relatedinjury.Thestatuterequiresareporttobeledwhenthe
worker'swholeorpartialincapacitycontinuesbeyondthe"day,turn,orshiftwhichsuchinjuriesaresustained"
astheresultofaccident."Incapacity"isnotspecicallydenedwithinthelaw,butthedivisionbelievesthatthe
Legislature'sintentwastoreferenceaworker'swholeorpartiallossoftheabilitytoperformhisorherordinary
jobtasks.Whenindoubt,keepinmindthelawcontainsnopenaltyforlingareportthatultimatelyprovestobe
unnecessary.There are penalties, however, for failing to le a report when one was required.Thepenalties
includenesandlimitationsonthedefensestheemployermayassertifaclaimisled.
OSHA Recordkeeping
TheemployermustcompleteanInjuryandIllnessIncidentReport,OSHAForm301,withinseven(7)daysof
learningthatawork-relatedinjuryorillnesshasoccurred.AccordingtoOSHA'srecordkeepingrule,youmustkeep
Form301,oranequivalentsubstituteonleforve(5)years.
TolearnmoreaboutOSHA'srecordkeepingrequirementsanddownloadforms,visit:
www.osha.gov/recordkeeping/RKforms.html
Page2of2KansasDepartmentofLabor
Accident Report
K-WC1101-A(Rev.10-13)
If you were hurt on the job and have any questions about workers compensation
benefi ts, contact the Ombudsman/Claims Advisory Unit of the Division of Workers
Compensation. The division has full-time personnel who specialize in aiding injured
workers with claim information and problems. They can provide information about
benefi ts an injured worker may be entitled to receive. They can help solve problems with
benefi ts not being paid on time, medical treatment, unpaid medical bills, questions about
how to fi gure settlement amounts, etc. Assistance in Spanish is available.
WHAT TO DO IF AN ACCIDENT OCCURS ON THE JOB
1. Tell your employer that you were hurt on the job.
2. Follow your employer’s instructions for getting medical aid and follow the doctor’s
instructions.
3. Within 200 days of the date of accident or date of last payment of compensation for
disability or date of last authorized medical care, tell your employer in writing that you
expect workers compensation benefi ts for your injury. Your employer might know you
were hurt and compensation may be paid, however, you could lose all rights to future
compensation if you do not tell the employer in writing. This is called a Written Claim for
Workers Compensation, K-WC 15, and is available from the division. A written claim may
be served in person by taking it to the employer to complete, sign, date top half and return
it to injured worker (injured worker completes bottom half), or by mailing it to the employer
by certifi ed mail, return receipt requested. The post offi ce receipt for the certifi ed letter is
generally suffi cient proof that you submitted a written claim.
AVERAGE WEEKLY WAGE: A worker’s “average weekly wage” is calculated by adding
together the base wage, the average weekly overtime and the weekly value of fringe
benefi ts that have been discontinued.
WEEKLY BENEFITS: Benefi ts are paid by the employer’s insurance carrier or self-
insurance program. Injured workers are not entitled to compensation for the fi rst week they
K-WC 27 (Rev. 4-06)
Information for Injured Employees
NOTICE: Employers are required to provide
this information to each injured worker.
Division of Workers Compensation
OMBUDSMAN/CLAIMS ADVISORY UNIT
800 SW Jackson Street, Suite 600
Topeka, KS 66612-1227
TOLL FREE 1-800-332-0353
are off work unless they lose three consecutive weeks. The fi rst compensation payment
is normally due at the end of the 14th day of lost time. An injured employee is entitled to a
weekly amount of 66 2/3 percent of his average weekly wage up to a maximum of 75 percent
of the state’s average weekly wage. These benefi ts are subject to legislative changes. If
the injury results in permanent disability, the Kansas workers compensation law provides for
additional benefi ts.
MEDICAL BENEFITS: An injured worker is entitled to all medical services reasonably
necessary to cure and relieve the worker from the effects of the injury. The employer has
the right to select the doctor who will treat the injury. A worker may seek the services of an
unauthorized doctor up to a limit of $500. A worker may apply to the Workers Compensation
Director to change the authorized treating doctor. Reimbursement for travel to obtain medical
treatment is payable at a rate set by law for trips that are fi ve miles or more (round trip).
1. Employers must report all employee injuries to the Division of Workers Compensation
within 28 days from the date of injury, or the date the employer learned about the injury,
when the employee is wholly or partially incapacitated for more than the remainder of the
day, turn or shift.
2. Employers must provide for the payment of workers compensation claims without any
charge to employees.
3. Employers must post the Workers Compensation Notice prepared by the Director.
4. Employers must pay compensation benefi ts, regardless of insurance coverage.
5. Upon receiving notice of an injury, the employer must provide the employee written
information to assist the injured worker in understanding his rights and responsibilities in
obtaining compensation.
YOUR CLAIM WILL BE HANDLED BY:
Company ____________________________________________________________________
Address ___________________________________________________________________
___________________________________________________________________
Contact Person _____________ _______________________________________________
Telephone (__________)_______________________________________________________
E-mail ____________________________________________________________________________
EMPLOYERS MUST COMPLETE THE FOLLOWING
INFORMATION FOR INJURED WORKERS
RESPONSIBILITIES OF THE EMPLOYER
ATENCIÓN
Los Empleadores Son Requeridos a Proporcionar
esta forma a cada Trabajador Lesionado
Llamada Gratis 1-800-332-0353
Consultores de Reclamos/Ombudsman
O Escriba A:
DIVISION OF WORKERS COMPENSATION
800 SW JACKSON STREET, SUITE 600
TOPEKA, KS 66612-1227
Si usted se ha lastimado en su trabajo, y tiene preguntas con respecto a los beneficios de la Compensación de
Trabajadores, comuníquese con la SECCIÓN DE CONSULTORES DE RECLAMOS/OMBUDSMAN de la
División de Compensación para Trabajadores de Kansas. Esta Divisón mantiene personal especializado en proveer
asistencia con problemas de reclamos y en dar información sobre estos a los trabajadores lastimados. Este per-
sonal le puede informar sobre los beneficios que un trabajador lastimado tiene derecho a recibir. También pueden
asistirle en resolver los problemas con respecto a los beneficios que no se le están pagando a tiempo, al tratamiento
médico, facturas de doctores que aún no se han pagado, y también con preguntas respecto a la cantidad del arreglo
(settlement). En la División de Compensación de Trabajadores hay asistencia disponible en Español.
¿QUE HACER SI LE SUCEDE UN ACCIDENTE EN EL TRABAJO?
1. Avísele inmediatamente al empleador que usted se ha lastimado en su trabajo. Dentro de 10 dias del accidente.
2. Siga las instrucciones del empleador con respecto al tratamiento médico, y siga las instrucciones del doctor.
3. Dentro de 200 días del accidente, o del último día en que le pagaron compensación por estar incapacitado, o en que
recibió tratamiento médico autorizado, avísele al empleador POR ESCRITO que usted espera recibir los beneficios
de compensacion de trabajodores por su accidente. Aunque su empleador ya se haya informado del accidente, y ya le
esté pagando los beneficios, usted puede perder el derecho de recibir compensación en el futuro, si no le avisa al em-
pleador POR ESCRITO. Esta documentación es lo que se llama AVISO POR ESCRITO (WRITTEN CLAIM).
El Aviso Por Escrito se puede entregar al empleador de dos maneras diferentes: Se lo puede entregar en persona, y al
mismo tiempo que se lo entrega, pídale un recibo. También se lo puede enviar por correo certificado, y el recibo será
su prueba de que envió el Aviso Por Escrito.
PROMEDIO DEL SUELDO SEMANAL:
Se calcula sumando lo siguiente: el sueldo básico, más un promedio de
horas extras trabajadas por semana, mas el valor semanal de cualquier beneficio adicional que haya sido descontinuado.
K-WC 270 (Rev. 3-05)
BENEFICIOS SEMANALES: Los Beneficios se los paga la compañiá aseguradora del empleador, o el programa
interno de seguros del empleador. El trabajador lastimado no recibe compensación por la primera semana que este sin
trabajar, A MENOS QUE esté sin trabajar por orden del doctor durante tres semanas consecutivas. El primer pago de
compensación normalmente se le debe al trabajador al terminar el catorceavo día de estar sin trabajar. Un trabajador
lastimado a causa del trabajo tiene derecho cada semana a una cantidad equivalente al 66 2/3% porciento del promedio
de su sueldo semanal, hasta llegar a un máximo equivalente al 75% porciento del promedio de sueldos semanales desig-
nado por el Estado de Kansas. Estos beneficios son sujetos a cualquier cambio que ordene la legislatura del estado. Si
el accidente resulta en una incapacidad permanente, la ley de compensación en Kansas le da derecho a otros beneficios
adicionales.
BENEFICIOS MEDICOS: Un trabajador lastimado tiene derecho a todo servicio médico razonable y necesario para
curar y aliviarle de los efectos del accidente. El empleador, tiene derecho a escojer el doctor para dar el tratamiento
médico necesario. El trabajador tiene derecho de escoger los servicios de otro doctor no autorizado hasta llegar al límite
máximo de $500.00 dólares. El trabajador puede pedirle al Director de la Division de Compensación de Trabajadores el
cambio de el doctor autorizado. Los gastos incurridos en viajes hechos para obtener tratamiento médico serán reembol-
sados según sean establecidos por la ley, siempre y cuando sean más de (5) cinco millas viaje redondo.
RESPONSABILIDADES DEL EMPLEADOR:
1. El empleador debe reportar cada accidente de los trabajadores a la División de Compensación de Trabajadores dentro
de 28 días de la fecha del accidente, o de la fecha en que el empleador se haya dado cuenta del accidente, cuando el
trabajador está completa o parcialmente incapacitado por lo que resta del día o del turno.
2. El empleador debe suministrar el pago de los reclamos sin cobrarles a los trabajadores.
3. El empleador debe exhibir un AVISO de Compensación al trabajador, preparado por el director.
4. El empleador debe pagar los beneficios de compensación aunque no tenga seguro.
5. En cuanto reciba aviso de un accidnete, el empleador debe proporcionar al trabajador información por escrito para
ayudarle a entender cuales son sus dercehos y responsabilidades al obtener compensación.
EL EMPLEADOR DEBE COMPLETAR LA SIGUIENTE INFORMACIÓN
PARA CADA TRABAJADOR LASTIMADO
SU RECLAMO SERA DIRIGIDO POR:
Compañía:_________________________________________________________________________________________
Dirección:_________________________________________________________________________________________
Contacto:__________________________________________________________________________________________
__________________________________________________________________________________________________
Teléfono:__________________________________________________________________________________________
www.dol.ks.gov KANSASDEPARTMENTOFLABOR K-WC40-A(4-13)
NOTIFIQUEASUEMPLEADORINMEDIATAMENTE.
De acuerdo con el artículo de ley K.S.A. 44-520, un reclamo puede
ser negado si el empleado no notica a su empleador dentro de
antes de las siguientes fechas: (A) 20días a partir de la fecha del
accidente o la fecha de la lesión debido a trauma por movimientos
repetitivos; (B) si el empleado está trabajando con el empleador
en contra del cual se están buscando benecios y dicho empleado
busca tratamiento médico por cualquier lesión por accidente o
trauma repetitiva, 20días a partir de la fecha que dicho tratamiento
médico ha sido obtenido; o (C) si el empleado ya no trabaja para el
empleador en contra del cual se están buscando benecios, 10días
después del último día de trabajo para dicho empleador.
El aviso puede darse oralmente o por escrito. Donde el aviso
se da oralmente, si el empleador ha designado un individuo o
departamento a quien el aviso se debe dar y tal designación ha sido
comunicada por escrito al empleado, aviso a cualquier otro individuo
o departamento deberá ser insuciente bajo esta sección. Si el
empleador no ha designado a un individuo o departamento a quien se
debe dar el aviso, el aviso puede darse a un supervisor o gerente.
Donde el aviso se hace por escrito, el aviso debe ser enviado
a un supervisor o gerente de la ocina principal de empleo del
trabajador.
El aviso, sea que se haga oralmente o por escrito, debe incluir
la hora, fecha, lugar, persona lesionada y detalles de tal lesión. Debe
ser visible a partir del contenido del aviso, que el empleado está
reclamando benecios bajo la ley de compensación del trabajador o
que ha sufrido una lesión relacionada con el trabajo.
BENEFICIOS.Losbeneciossonpagadosporlacompañía
aseguradoradelempleadoroprogramadeseguropropio. Los
benecios incluyen tratamiento médico, reemplazo de sueldo parcial
por tiempo perdido y benecios adicionales si la lesión resulta en
incapacidad permanente. El empleador debe proporcionar todo el
tratamiento médico necesario y tiene el derecho de designar el doctor
para dicho tratamiento. Si el empleado busca tratamiento con un
doctor que no ha sido autorizado por el empleador, el empleador o
su compañía aseguradora serán responsables de pagar solamente los
primeros $500.00 dólares para tratamiento médico no autorizado.
Employer’s Insurance Carrier (Compañía Aseguradora del Empleador) Telephone (Teléfono de la Aseguradora)
KANSAS DEPARTMENT OF LABOR
Division of Workers Compensation/Ombudsman
401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105
Persons with impaired hearing or speech utilizing a telecommunications device may access the above number(s) by using the Kansas Relay Center at (800) 766-3777.
ThisnoticeappliestodatesofaccidentsonorafterApril25,2013.
EsteavisoaplicaalasfechasdelosaccidentesapartirdeAbril25,2013.
NOTIFYYOUREMPLOYERIMMEDIATELY.Per
K.S.A. 44-520, a claim may be denied if an employee fails to
notify their employer within the earliest of the following dates:
(A) 20calendardays from the date of accident or the date of
injury by repetitive trauma; (B) if the employee is working for
the employer against whom benets are being sought and such
employee seeks medical treatment for any injury by accident or
repetitive trauma, 20calendardays from the date such medical
treatment is sought; or (C) if the employee no longer works for
the employer against whom benets are being sought,
10calendardays after the employee’s last day of actual work
for the employer.
Notice may be given orally or in writing. Where notice is
provided orally, if the employer has designated an individual or
department to whom notice must be given and such designation
has been communicated in writing to the employee, notice to
any other individual or department shall be insufcient under
this section. If the employer has not designated an individual
or department to whom notice must be given, notice must be
provided to a supervisor or manager.
Where notice is provided in writing, notice must be sent to
a supervisor or manager at the employee’s principal location of
employment.
The notice, whether provided orally or in writing, shall
include the time, date, place, person injured and particulars
of such injury. It must be apparent from the content of the
notice that the employee is claiming benets under the workers
compensation act or has suffered a work-related injury.
BENEFITS.Benetsarepaidbytheemployer’s
insurancecarrierorselfinsuranceprogram. Benets include
medical treatment, partial wage replacement for lost time and
additional benets if the injury results in permanent disability.
An employer is required to furnish all necessary medical
treatment and has the right to designate the treating physician.
If the employee seeks treatment from a doctor not authorized by
the employer, the employer or its insurance carrier is only liable
up to $500.00 dollars for the unauthorized medical treatment.
WHERETOGETHELPWITHYOURCLAIM(DÓNDECONSEGUIRAYUDACONSURECLAMO):
Website: www.dol.ks.gov/workcomp/default.aspx
Email: wc@dol.ks.gov
Phone: (800) 332-0353 or (785) 296-4000
ForquestionsaboutWorkersCompensationLaw,contact(ParapreguntasacercadelaLeydeCompensacióndelTrabajador):
Address (Dirección de la Aseguradora)
WHATTODOIFANINJURY
OCCURSONTHEJOB
QUEHACERSIUNALESIÓN
OCURREENELTRABAJO
( )
This notice must be posted and maintained by the employer in one or more conspicuous places.
Your employer is subject to the Kansas Workers Compensation Law which provides compensation for job-related injuries.
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ACCIDENT REPORT www.dol.ks.gov SEE INSTRUCTIONS ON PAGE 2 (National American Insurance Company)

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Completed 29 July 2021

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