Current through Reg. 49, No. 38; September 20, 2024
(a) An employer that does not have workers'
compensation insurance coverage (non-subscriber) and employs five or more
employees not exempt from workers' compensation insurance coverage shall file
with the division a report of each:
(1)
death;
(2) on-the-job injury that
results in more than one day's absence from work for the injured employee;
and
(3) occupational disease of
which the employer has knowledge.
(b) An employer shall file a report required
by subsection (a) of this section with the division not later than the seventh
day of the month following the month in which:
(1) the death occurred;
(2) the employee was absent from work for
more than one day as a result of the on-the-job injury; or
(3) the employer acquired knowledge of the
occupational disease.
(c) A report shall be filed in writing or
electronically and shall be in the form and manner prescribed by the division.
A report must include:
(1) the employer's
business name;
(2) the employer's
North American Industry Classification System (NAICS) codes;
(3) the employer's business mailing
address;
(4) the employer's
physical address (if different from mailing address);
(5) the employer's telephone
number;
(6) the employer's federal
employer identification number (FEIN);
(7) the name, title, telephone number,
signature, and date of signature of the person completing the report for the
employer;
(8) the reporting
period;
(9) the injured employee's
name;
(10) the employee's social
security number;
(11) the
employee's date of birth;
(12) the
employee's date of hire;
(13) the
employee's sex;
(14) the employee's
occupation;
(15) the employee's
hourly wage;
(16) the employee's
NAICS code;
(17) the employee's
race/ethnic identification;
(18)
the address where injury or occupational disease occurred;
(19) the type of location of where injury or
occupational disease occurred;
(20)
the date of injury or occupational disease;
(21) the date reported by employee;
(22) the return-to-work date or expected
date;
(23) the reported cause of
injury;
(24) the nature of injury
or occupational disease;
(25) any
equipment involved in the injury;
(26) body part(s) affected;
(27) the first day of absence from
work;
(28) the number of days
absent from work;
(29) whether the
injury is an occupational disease;
(30) whether the injury resulted in death;
and
(31) a description of
incident.
(d) Employers
are responsible for timely and accurate filing of reports under this section. A
report required by this section is considered filed with the division only when
it accurately contains all of the data elements specified under subsection (c)
of this section and is received by the division.
(e) This section is effective January 1,
2013.
