Workers Compensation Claims Reporting. What do I do after a Workers Compensation accident occurs?

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1 Workers Compensation Claims Reporting What do I do after a Workers Compensation accident occurs? Secure medical treatment for your injured employee. If during normal business hours, use an Occupational Medicine Clinic instead of an emergency room. The cost savings can be significant. If you need assistance locating a clinic, please contact us at If possible, have the injured employee complete an Employee Accident Report Form before seeking treatment, to gather information about the accident in the injured employee s own words. Management personnel on premises at the time of the incident should complete the Supervisor s Accident Investigation Form to gather the facts surrounding the incident including any witnesses to the incident. If you have a drug/alcohol screening policy in effect, have employee submit to a post-accident drug/alcohol screen as soon as the injury is reported to you, even if the accident occurred several days prior. If injured employee refuses drug/alcohol screening or medical treatment, have employee complete the appropriate refusal forms. Report the claim by phone to LRA/SIF Claims Management at or on line at as soon as possible following the injury/accident.. After reporting the injury/accident, the Intake Operator will provide you with an LRA/SIF Claim Number. Referencing the Claim Number will help expedite the handling of the rest of the claim. Please include the Claim Number with all future correspondence, such as wage statements, medical bills, etc. Forward a copy of the employee s LA OWCA Second Injury Board Knowledge Questionnaire to the LRA/SIF claims office by fax to (504) If your employee is not able to return to work full duty immediately following an injury/accident, cooperate with the LRA/SIF to identify modified or transitional duty work where appropriate. Modified or transitional duty work helps the employee recover more quickly, both mentally and physically and can mean tremendous cost savings on your workers compensation claim. Should you have any questions or concerns, please contact the LRA/SIF Claims office at the telephone number above for assistance with the claim.

2 Louisiana Restaurant Association Self Insurer s Fund EMPLOYEE ACCIDENT REPORT EMPLOYEE INFORMATION Name SSN# Address City State Zip Sex M F Date of Birth Age Home Phone Cell Job Title Department Full Time Part Time ACCIDENT INFORMATION Accident Date Time am pm Time Shift Began am pm Location of accident (Be Specific What were you doing before the accident occurred? Explain how the accident occurred Was this part of your normal job duty? Explain Were you wearing any personal protective equipment (PPE)? (gloves, mask, etc..) If so please list Should you have worn PPE? Yes No Indicate the part(s) of your body affected or injured Person to whom the accident was reported When reported List all witnesses to the accident By my signature below I attest that the information contained on this form is true to the best of my knowledge and that no false statements were made or given when completing this form. SIGNATURE OF EMPLOYEE: DATE

3 Louisiana Restaurant Association Self Insurer s Fund SUPERVISOR'S ACCIDENT INVESTIGATION REPORT Company Name Address Name of Injured Employee SSN# Address City State Zip Date of accident Time am pm Was employee on duty at the time of accident? Yes No Was employee on company premises? Yes No Describe accident in detail Part(s) of body injured Did employee leave work? Did employee return to work? Yes No Date Time am pm Yes No Date Time am pm Did employee seek medical attention? If so, name/phone of provider ANALYSIS Was the accident investigated? Yes No Do the facts indicate the injury was work related? Yes No What were the causes of the accident? Was a piece of machinery, equipment or guard the reason for the injury? If so, explain Could employee have avoided being injured? (Wearing Safety equipment, using guards, etc ) If so, explain What preventative measures can be taken to prevent future recurrence? Should this claim be questioned? If yes, why List all witnesses to the accident Supervisor s Signature Accident reported to me: Date Time am pm

4 Louisiana Restaurant Association Self Insurer s Fund WITNESS REPORT Today s Date Name Telephone/Cell Address Witness to event of Date of event In your own words, state actual facts that you saw or heard: What did you witness immediately prior to the incident? What did you witness during the actual incident? What did you witness after the incident? If you actually saw the entire event, what do you feel to be the cause of the incident? Signature Date Please write on back if you need more room

5 Workers Compensation Instructions and Medical Release Employer s Name & Address: Member/Policy #: Contact Person: Phone #: Employee s Name & Address: Employee s Phone #: Date/Time of Accident: CHECK HERE IF: POST ACCIDENT DRUG / ALCOHOL TEST SHOULD BE CONDUCTED I, the undersigned, authorize any physician, physician s assistant or nurse who has attended me, or any hospital at which I have been confined, to furnish to any authorized representative of LRA/SIF Claims Management, any and all information which may be requested regarding my condition and/or treatment, and to allow them to examine and copy any radiographic pictures or records regarding my condition or treatment. I specifically authorize said physicians, nurses and hospitals to communicate said information by any reasonable means, including written or telephonic communication or by direct interview, whether or not I am present during or notified of such communications, and I hereby authorize LRA/SIF Claims Management to initiate and conduct such communications whether or not I am present or have notice thereof. A photostatic or faxed copy of this release is to be given the same force and effect as the original. Employee Signature: Date: Medical Provider Please forward all pertinent medical information directly to my Workers Compensation carrier at the address below: Louisiana Restaurant Association Self Insurer's Fund (504) P. O. Box 6990 (877) (Toll Free) Metairie, LA (504) (Fax)

6 REFUSAL OF POST ACCIDENT MEDICAL ATTENTION THIS SECTION TO BE COMPLETED BY EMPLOYER: Date: Business Name: Phone: Address, City, Zip: Employee s Name (Print): D/O/B: Was involved in a work-related accident on (Day & Date): He/She described what happened as follows: Medical attention was offered to employee and refused on (Day & Date): Company Representative: Title: Day & Date Signed: THIS SECTION TO BE COMPLETED BY THE EMPLOYEE I understand that my signature on this form does not relieve my employer from their Workers Compensation responsibility for an injury that may have occurred as a result of my work-related accident. My signature on this form does indicate that I was offered medical attention by my employer for this work-related accident, but I refused it at this time. I understand that I am not required to sign this form as a condition of my continued employment. I willingly sign this form to indicate that my employer has offered me medical attention as a result of the incident listed above, but I feel such medical attention to be unnecessary at this time. Signature of Employee: Day & Date Signed: Forward Completed Form to: Louisiana Restaurant Association Self Insurer s Fund P.O. Box 6990 Metairie, LA (504) (877) FAX (504)

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