These sample accident report forms are free to use and share.
L&I Accident Report Form Pdf. How to file an l&i claim if you suffer an injury at work or develop an occupational disease, you need to file a claim right away. Web do not send the completed form to this office.
These sample accident report forms are free to use and share.
Due to the volume of requests for. The best way to file. Send chart notes and reports to l&i or sie/tpa as required. Department of labor (see instructions on reverse) office of workers' compensation programs omb no. Email name phone preparer's signature use this form to report injuries or property damage sustained by visitors, students or the general. Web report of accident (roa) form: Employer's address and zip code 30. A three car accident, add another report form as needed. Filing this form does not constitute an admission of liability. 1073m (guidance on back) reminder:
Send chart notes and reports to l&i or sie/tpa as required. Web activity prescription form (apf) billing code: Web do not send the completed form to this office. Report of industrial injury or occupational disease form. Web kansas department of labor. Employer's telephone number ( ) 31. Web if you will be working at a location without internet access, download and save or print the accident/incident report form (pdf) prior to leaving internet service. Web report of accident (roa) form: 401 sw topeka blvd, suite 2. However, the report / case / incident number is required on each. Due to the volume of requests for.
