Form 122E               EMPLOYER’S FIRST REPORT OF INJURY OR ILLNESS                                                  Rev 10/2019 
TO BE COMPLETED BY EMPLOYER WITH ORIGINAL SENT TO INSURANCE CARRIER AND COPY SENT TO INJURED WORKER 
INJURED WORKER INFORMATION: 
Name:                                                           Phone: 
Address:                                                        City:                        State:                    Zip: 
Social Security Number:                                         Date of Birth: 
Marital Status:                                                 Sex:      Male           Female           Unknown     
Occupation / Job Title:                                         Date Hired: 
Employment Status:                                              Number of Dependents: 
Wage:                                          Wage Period:     Daily                Weekly                  Monthly           
Full Pay for Day of Injury:    Yes           No               Number of Days Worked per Week: 
EMPLOYER INFORMATION: 
Business Name:                                                  Phone: 
Employer Contact:                                               Phone: 
Mailing Address:                                                City:                        State:                    Zip: 
Employment Address:                                             City:                        State:                    Zip: 
Employer FEIN: 
INSURANCE INFORMATION: 
Carrier:                                                        Phone: 
Carrier Address:                                                City:                        State:                    Zip: 
Policy / Self-Insured Number:                                   Policy Period: 
OCCURRENCE/TREATMENT: 
Date of Injury / Disease:                     Time of Injury:                       Date Employer Notified: 
Nature:                                       Body Part:                            Cause: 
Last Day Worked:                              Date Disability Began:                Date Returned to Work: 
Fatality:     Yes           No                Date of Death:                        Date Administrator Notified: 
Address of Occurrence:                                          City:                        State:                    Zip: 
Premises:     Employer’s           Other           Description: 
Accident Description: 

Provider Injured Worker Received Care From: 
Provider Address :                                              City:                        State:                    Zip: 
Treating Physician:                                             Phone: 
Initial Treatment:   No Medical Treatment           Minor: By Employer           Minor: Clinic/Hospital           Emergency Care       
                                     Hospitalized- 24 Hours           Future Major Medical/Lost Time Anticipated      
Witnesses:     Yes           No           If yes list their names and phone number: 

For your protection, it is required by Utah Law to give notice that workers’ compensation fraud is a crime. See next page for full 
fraud statement.  

                        160 East 300 South 3rdFloor P.O. Box 146610 Salt Lake City, Utah 84114-6610 
          Office: (801)-530-6800 Fax: (801)-530-6804 Toll Free: (800)-530-5090 www.laborcommission.utah.gov 

 Form 122E   EMPLOYER’S FIRST REPORT OF INJURY OR ILLNESS                                 Rev 10/2019 
                                   INSTRUCTIONS TO THE EMPLOYER 
PLEASE NOTE: 

The filing of this form does not admit liability or fault. However, failure to file this report with the insurance 
carrier and provide a copy to the injured worker can result in a citation and civil penalty for each violation as 
per §34A-2-407(8), U.C.A.  

The insurance carrier is to receive the original of this form. The injured worker shall then receive a copy 
along with their rights and obligations of the Utah’s Workers’ Compensation Act (Form 100). The employer 
should keep a copy for their records. The Labor Commission, Division of Industrial Accidents, will receive an 
electronic copy from the insurance carrier. The electronic copy of this form is private information and only 
released to parties of the claim.  

In order to dispute the validity of the injured worker’s claim, contact the insurance carrier or claim 
administrator for more information.  

All fields on this form are required. Please complete this form entirely and do not leave any blank fields. This 
form will be returned and additional information will be requested if it is not properly completed. If you, the 
employer, need assistance to complete the form contact your workers’ compensation insurance carrier or 
claims administrator. 
 Rule R612-200-1(A)(2) Except for injuries treated only by first aid, an employer shall report each employee 
work injury within 7 days after receiving initial notice of the injury, as follows: 

 a.An employer that has obtained workers' compensation insurance shall report the injury to its
 insurance carrier.

 b.An employer that has received Division authorization to self-insure shall report the injury to its
 claims administrator.

 c.An employer that has failed to obtain worker's compensation coverage shall report the injury by
 contacting the Division directly.

3.An employer has notice of a work injury upon the earliest of:

 a.Observation of the injury;

 b.Verbal or written notice of the injury from any source; or

 c.Receipt of any other information sufficient to warrant further inquiry by the employer.

FRAUD WARNING: 

Any person who knowingly presents false or fraudulent underwriting information, files, claim for disability 
compensation, medical benefits, health care fees, or other professional services are of guilty of a crime and 
may be subject to fines and confinement in state prison.  

             160 East 300 South 3rdFloor P.O. Box 146610 Salt Lake City, Utah 84114-6610 
 Office: (801)-530-6800 Fax: (801)-530-6804 Toll Free: (800)-530-5090 www.laborcommission.utah.gov