A Form 19 must be completed in its entirety and no section may be left blank. It is very important that this form is accurate, as it is the employer’s initial contact with the Industrial Commission. Of course, the first information asked for on the form is the employees, employers and their insurance carrier’s contact information. They then ask what the nature of the employer’s business is and then go into requesting information about the specific injury. The employer must list the location the injury occurred, the county and department where the injury occurred and must specify if the state that the injury occurred in is the same state where the employee resides.
The form then requests the basic information of date, day of week and the time of day that the injury occurred. The employer must list if the employee was paid for the entire day or not and also the date that the employee’s disability pay began. The form also requests the name of the supervisor on duty at the time of the injury and the date that the employer or supervisor first knew about the injury. The employer must then disclose the employee’s occupation, how long the employee have worked for them, what the hourly wage is and the average number of hours a day that the employee works. They must also disclose any average overtime that they employee works and an average amount of reimbursement for expenses that they pay the employee, if any.
The employer must then describe in detail how the injury occurred and what the employee was doing at the time of the injury. They must also state if the employee was treated by a physician after the injury. If the injury resulted in the death of the employee, the employer must disclose the date of death and also submit a Form 29.