Form 122E 2026

See details

4.8 out of 5

102 votes

The document is the 'Employer’s First Report of Injury or Illness' (Form 122E) used in Utah, which employers must complete to report workplace injuries or illnesses. It requires detailed information about the injured worker, employer, insurance details, and specifics of the injury or illness. The form must be submitted to the insurance carrier and a copy provided to the injured worker. It emphasizes compliance with reporting requirements and warns against workers' compensation fraud.

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out Form 122E with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open Form 122E in the editor.
Begin by filling out the Injured Worker Information section. Enter the worker's name, phone number, address, and Social Security Number. Ensure all fields are completed accurately.
Next, provide details in the Employer Information section. Include your business name, contact information, and mailing address. This ensures proper communication regarding the claim.
In the Insurance Information section, input the carrier's details and policy numbers. This is crucial for processing the claim efficiently.
Complete the Occurrence/Treatment section by detailing the date of injury, nature of injury, and any medical treatment received. Be thorough to avoid delays.
Finally, review all entries for accuracy before submitting. Use our platform’s features to save or print a copy for your records.

Start using our platform today to fill out Form 122E easily and for free!

See more Form 122E versions

We've got more versions of the Form 122E form. Select the right Form 122E version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (102 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the most frequently reported claim at work?

Commonly reported work-related incidents and injuries include: Slips, trips, and falls. Overexertion. Repetitive strain injuries. Falling objects. Machinery and vehicle accidents. Exposure to harmful substances. Occupational illnesses.

What is the most common workers comp claim?

Common Causes of Workers Compensation Claims Strains and Sprains. Strains and sprains are by far the most common on-the-job injury for workers. Cuts and Punctures. Severe Cuts and Lacerations. Overuse or Repetitive Stress Injuries, Including Back Injuries. Fractures.

How to claim workmen compensation?

If the employer is lying to the carrier, saying that the employee did not report it when he did, in fact, report it, then that could be considered Workers Compensation fraud, which is a crime. It probably will not mean any extra benefits for the employee.

How do you document an employee injury?

File a workers claim for compensation form with their Workmen Compensation Insurance provider. Gather relevant documentation, including the employees wage and attendance records, accident report, and any medical bills incurred.

What is the most common workers compensation claim?

How to Document a Workplace Injury Get to the site as quickly as possible. Ensure the area is safe to enter. Make sure the injured/ill person is receiving first-aid or medical attention. Identify any witnesses. Record the scene with photos (ideally with date and time stamp) or sketches. Safeguard any evidence.

Security and compliance

At DocHub, your data security is our priority. We follow HIPAA, SOC2, GDPR, and other standards, so you can work on your documents with confidence.

Learn more

Related forms

be ready to get more

Complete this form in 5 minutes or less

Get form

What is the highest paid workers comp case?

In an accomplishment, RITE Firm from Jacksonville, Florida, has broken records with the largest workers compensation settlement ever seen in the United States. Led by Partner Michael Rudolph, they finalized a deal valued at $13.5 million with the potential to docHub over $21 million when considering annuities.

What is the most basic and common form of employee compensation?

Base salary forms the foundation of compensationthe fixed amount employees receive regularly for fulfilling their job responsibilities. It provides financial stability and serves as the benchmark against which other compensation elements are measured.

Form 122E 2026

Here's how it works