Employee Guidelines for Workers Compensation Accidents

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Employee Guidelines for Workers Compensation Accidents"

Transcription

1 Employee Guidelines for Workers Compensation Accidents The information included in this packet will become important to you in the event that you seek medical attention or lose time from work due to a work- related injury or illness. The following provides a brief description of the documents included in this packet and how they are to be used: Employee s Report of Work Related Injury This form should be completed by the injured employee, if able to do so, and forwarded to the HR Director. Supervisor s Report of Work Related Injury The Supervisor s Report of Injury Report should be completed as soon as possible, but definitely within three (3) business days of the accident and forwarded to the HR Director. Delay in notification could result in denial of payment for any medical services rendered. Witness Statement for Work Related Injury This form should be completed by any witness to the accident. If there were more than one witness, a separate form should be completed by each witness. Once completed, the supervisor of the injured employee should forward to the HR Director. Procedures: Report the accident immediately to your supervisor no matter how insignificant it may seem. Give your supervisor all information regarding the accident so he or she can notify the appropriate personnel. If the injury necessitates medical attention, you need to select a doctor from the Panel of Physicians. The Panel of Physicians and Bill of Rights for Injured Employees are posted at each facility within Polk School District. In case of an emergency, you may seek medical treatment from any doctor/emergency facility until the immediate emergency is over. However, any additional medical treatment you receive must be provided by a doctor on the Panel of Physicians. When you arrive at the doctor s office or the hospital let the nurse know that AmTrust administers your workers compensation program. Once AmTrust receives your injury report, your claim will be assigned to an adjuster. The adjuster will complete an investigation and advise you with regard to the status of your claim. If the investigation concludes that your injury meets the criteria established by state law, you will receive all benefits to which you are entitled under the Workers Compensation Act. If the adjuster s investigation discloses a non- covered injury, you will be notified in writing of the denial. If you are losing time from work, stay in contact with your claims adjuster. He or she will guide you through the rehabilitation process and help you return to work as soon as possible. If you have questions regarding your workers compensation coverage, contact the Human Resources at (770) or the AmTrust at (866) for additional information. Claim Reporting Information AmTrust North America P.O. Box Atlanta, GA (866) phone (877) fax inc.com

2 Employee s Report of Work Related Injury Employee should complete this form as soon as possible after an incident. ALL questions should be answered. Employee SS# Job Title BOE Location Normal work hours to Date of Birth Age Gender Home phone number Did you have an injury by accident while working for the Polk School District? Date of injury Time AM/PM Place of injury What part of the body was injured? (Right hand, left foot, etc) What type of injury? (Burn, Sprain, Broken bone, etc) State what you were doing at time of accident? (Be specific) How did accident or exposure occur? (Describe contributing events, conditions, or personal actions; How and why did accident occur; How could this have been prevented?) Who was injury reported to? Date reported Who saw the accident happen? Did you leave work as a result of the injury? Time left work Did you seek medical aid? Name and address of treating physician If medical treatment is required, please list all medication that you are taking (prior to injury). Are you employed with any employer other than Polk School District? If so, name of employer and position held: Employee signature Date Supervisor signature Date Any additional information, which is pertinent to this claim, should be attached.

3 Supervisor s Report of Work Related Injury A supervisor should investigate the incident thoroughly and as quickly as possible and answer ALL of the following questions. Employee SS# Job Title BOE Location Date hired Date of Birth Age Gender Home phone # Hours worked per day Normal work hours To Date of injury Time AM/PM Place of injury Who was injury reported to Date reported List of all witnesses to incident What part of the body was injured? (right hand, left foot, ect) What type of injury? (burn, sprain, broken bone, etc.) What was employee doing at time of accident? (Be specific) How and why did accident or exposure occur? (Describe contributing events, conditions, or personal actions; how could this have been prevented? Did the employee seek medical treatment? Yes No Name and address of treating physician Was emergency care required? Yes No If Yes, name of facility Was ambulance required? Yes No Did employee leave work as a result of the injury? Yes No Time left work Did employee work the next day following injury? Yes No First date employee failed to work a full day If returned to work, date Signature of reporting supervisor Date Signature of Principal/Director Date

4 Witness Statement for Work Related Injury Name of injured employee Your name Phone number Work location For how long? How long have you known the injured employee? How long have you worked with him/her? When did the injured employee state the incident occurred? When did you first become aware of the incident? Date Time Did you see the accident occur? What did the injured employee first say to you about the injury? What part of their body was injured? (Right hand, left foot, etc.) What type of injury? (Burn, sprain, broken bone, etc.) What was the employee doing at time of accident? (Be specific) How and why did accident or exposure occur? (Describe contributing events, conditions, or personal actions) How could the accident have been prevented? Was the accident reported? To whom? List all witnesses to accident In your opinion, did the injury possibly occur other than as alleged by the injured employee? If yes, please explain Please list any other information you feel should be considered in evaluating this claim. Witness Signature Date Any additional information, which is pertinent to this claim, should be attached.

5 PROCEDURES TO FOLLOW WHEN ASSISTING AN INJURED EMPLOYEE Educate all employees to immediately report any accident to their supervisor. Review the List of Panel of Physicians and select the appropriate physicians or primary care provider. Post the List of Panel Physicians in a conspicuous location. Once an injury is reported: 1. Provide the injured employee with the appropriate List of Panel of Physicians. In the event of serious injury, bypass the Panel of Physicians and send the injured employee directly to the emergency room or a specialist. 2. Call the Physician and advise him or her that the injured employee is on the way to the facility. If referral to a specialist is necessary, authorization from the AmTrust adjuster is needed. 3. Direct the employee to follow up with his or her supervisor immediately following every physician or provider visit. This will allow you to remain aware to the employee s work status. Please immediately forward all work status and medical documents provided by the physician or provider to Human Resources. 4. It is important to make every effort to provide modified or light duty work, when possible, to get the injured employee back on the job as soon as possible. Doing so can significantly reduce the overall cost of lost time claims. 5. For any injury resulting in medical treatment (other than on- site first aid), complete the Supervisor s Report of Work Related Injury immediately, but no later than three (3) days from the occurrence or knowledge of the injury.

For Employees: Employees: What What to to do do when when an an accident occurs 08/19/14/dmv

For Employees: Employees: What What to to do do when when an an accident occurs 08/19/14/dmv For Employees: What to do when an accident occurs 08/19/14/dmv When there is a work-related accident or illness, procedures must be taken to ensure the employees needs are met with respect to treatment

More information

ACCIDENT REPORTING PROCEDURE

ACCIDENT REPORTING PROCEDURE ACCIDENT REPORTING PROCEDURE 1. Employee must notify supervisor immediately. 2. Employee must complete Workers Compensation form 1A (Employee s First Report of Injury) immediately following the accident

More information

Workers' Compensation

Workers' Compensation Workers' Compensation Accident Reporting Procedures LISD FORMS AVAILABLE AT THE SAFETY WEBSITE ARE IN BOLD LETTERS 1. Employee reports accident or near miss to campus/department Safety Officer. The Safety

More information

WORKERS COMPENSATION. Office of Human Resources

WORKERS COMPENSATION. Office of Human Resources WORKERS COMPENSATION Office of Human Resources WHAT IS WORKERS COMPENSATION? Workers Compensation is a University paid benefit for employees and students that are working payroll or work study. Workers

More information

TEXAS DEPARTMENT OF CRIMINAL JUSTICE Supervisor s Report Packet for Workers Compensation CONTENTS

TEXAS DEPARTMENT OF CRIMINAL JUSTICE Supervisor s Report Packet for Workers Compensation CONTENTS Supervisor s Report Packet for Workers Compensation CONTENTS PERS 299-1, Supervisor s Guidelines for Workers Compensation PERS 299-2, Witness Statement PERS 299-3, Supplemental Worksheet PERS 299 (09/15)

More information

Workers Compensation Claim Kit PRAIRIE STATE INSURANCE COOPERATIVE

Workers Compensation Claim Kit PRAIRIE STATE INSURANCE COOPERATIVE Workers Compensation Claim Kit PRAIRIE STATE INSURANCE COOPERATIVE A CMI, A York Risk Services Company, publication November 1, 2013 Table of Contents About CMI.... 1 To Report a Claim... 1 The Importance

More information

Injury Illness Response and Reporting Procedure

Injury Illness Response and Reporting Procedure Injury Illness Response and Reporting Procedure Policy: The following is the procedure for reporting and response to injuries or illnesses for employees, students, official volunteers and/or visitors at

More information

Workers' Compensation CLAIMS KIT

Workers' Compensation CLAIMS KIT Workers' Compensation CLAIMS KIT CLMCVR ATTENTION WORKERS' COMPENSATION POLICYHOLDERS! Thank you for placing your Workers' Compensation insurance through CIA Managing General Agency. The carrier for your

More information

The Seubert Safe Workplace

The Seubert Safe Workplace The Seubert Safe Workplace The Seubert Safe Workplace is a program initiated to help our commercial insurance clients their control worker compensation costs and improve employee health and well-being.

More information

CLAIMS REPORTING TO REPORT AN INJURY CALL 1-866-274-6033. 24 hours a day / 7 days a week

CLAIMS REPORTING TO REPORT AN INJURY CALL 1-866-274-6033. 24 hours a day / 7 days a week CLAIMS REPORTING TO REPORT AN INJURY CALL 1-866-274-6033 24 hours a day / 7 days a week You will need the following information to report a claim. However, do not delay reporting if you are missing information.

More information

(This is a sample of the injury packet that GENEX will customize for each employer)

(This is a sample of the injury packet that GENEX will customize for each employer) Ohio Workers Compensation Injury Packet (This is a sample of the injury packet that GENEX will customize for each employer) Employer: «Employer» «Address1» «City», «ST» «Zip» Phone #: «Phone» BWC Policy

More information

What to Do When an Accident Occurs - Work Comp Procedures

What to Do When an Accident Occurs - Work Comp Procedures What to Do When an Accident Occurs - Work Comp Procedures Immediate Response Non-emergency Respond with onsite first aid/cpr responders. Employee must select a physician from the Panel of Physicians form

More information

SCHOOL POOL FOR EXCESS LIABILITY LIMITS

SCHOOL POOL FOR EXCESS LIABILITY LIMITS SCHOOL POOL FOR ECESS LIABILITY LIMITS JOINT INSURANCE FUND ACCASBOJIF, BCIPJIF, & GCSSDJIF CLAIM COORDINATOR MANUAL S P E L ACCASBO L BCIP GCSSD SEJIF I F REVISED OCTOBER 2013 Section 2 WORKERS COMPENSATION

More information

Madison County Board Of Education

Madison County Board Of Education JOB-RELATED INJURY INSTRUCTIONS In compliance with Board Policy FILE: 5.9.4, Absences Due to Job-Related Injuries, the following instructions must be followed when injuries occur on the job. Please read

More information

Office of Human Resources Standard Operating Procedure HR SOP #021

Office of Human Resources Standard Operating Procedure HR SOP #021 Office of Human Resources Standard Operating Procedure HR SOP #021 Subject: Workers Compensation Effective Date: April 1, 2014 Policy Statement: The Department of Natural Resources (DNR) will coordinate

More information

Frequently Asked Questions About Georgia Workers Compensation Ty Wilson Attorney At Law 1-866-937-5454 www.tywilsonlaw.

Frequently Asked Questions About Georgia Workers Compensation Ty Wilson Attorney At Law 1-866-937-5454 www.tywilsonlaw. Frequently Asked Questions About Georgia Workers Compensation Ty Wilson Attorney At Law 1-866-937-5454 www.tywilsonlaw.com Special Report Frequently Asked Questions About Claims Special Report Ty Wilson

More information

Employee s Report of Work-Related Injury University of Maryland, College Park

Employee s Report of Work-Related Injury University of Maryland, College Park Employee s Report of Work-Related Injury To be completed immediately after the accident or initial treatment and submitted to your supervisor Employee Name: UID: Male (First) (Last) Female Date of Birth:

More information

Superintendent s Circular

Superintendent s Circular Superintendent s Circular School Year 2011-2012 NUMBER: HRS-PP7 DATE: WORKERS COMPENSATION PROCEDURES OBJECTIVE The Boston Public Schools Workers Compensation Service is located within Boston City Hall,

More information

University of Virginia Facilities Management Department. Workers Compensation Packet

University of Virginia Facilities Management Department. Workers Compensation Packet University of Virginia Facilities Management Department Workers Compensation Packet Last Revised February 2013 Checklist for Workers Compensation Claims Report the accident to your supervisor immediately.

More information

THIS FORM MUST BE ENTIRELY COMPLETED IN ORDER TO PROCESS YOUR CLAIM

THIS FORM MUST BE ENTIRELY COMPLETED IN ORDER TO PROCESS YOUR CLAIM THIS FORM MUST BE ENTIRELY COMPLETED IN ORDER TO PROCESS YOUR CLAIM COBB COUNTY SCHOOL DISTRICT EMPLOYEE REPORT OF WORK RELATED ACCIDENT (770) 590-4520 FOR WORKERS COMPENSATION (678) 594-8266 Office Fax

More information

SECTION 2: Support to Employees HEALTH AND SAFETY POLICY: WORKPLACE SAFETY AND INSURANCE BOARD (WSIB)

SECTION 2: Support to Employees HEALTH AND SAFETY POLICY: WORKPLACE SAFETY AND INSURANCE BOARD (WSIB) Page 1 of 5 POLICY 1. Community Living Quinte West shall take all reasonable precautions to protect all employees from illness and injury. 2. The employer shall work cooperatively with employees, the bargaining

More information

Long-Term Disability Income Benefit. Employee s Statement

Long-Term Disability Income Benefit. Employee s Statement Long-Term Disability Income Benefit Employee s Statement Employee s Statement Long Term Disability Income Benefits This guide explains how to apply for Long Term Disability benefits. It contains the form

More information

Central State University (CSU) ACCIDENT PROCEDURE

Central State University (CSU) ACCIDENT PROCEDURE Central State University (CSU) ACCIDENT PROCEDURE Note: Copies of all injury reporting packets are located in your department office and/or Human Resources Department. Complete this form when the answer

More information

Incident / Accident Report Form

Incident / Accident Report Form Incident / Accident Report Form This form is to be completed in the event of any incident whether injury has occurred or not. WORKERS SUBMIT FORM TO YOUR MANAGER VISITORS/CONTRACTORS/STUDENTS SUBMIT FORM

More information

WORKERS COMPENSATION CLAIM REPORTING PROCEDURES

WORKERS COMPENSATION CLAIM REPORTING PROCEDURES WORKERS COMPENSATION CLAIM REPORTING PROCEDURES 1. Complete the enclosed First Report of Injury to ensure that you will have all of the appropriate questions answered during the reporting process. Have

More information

HANOVER COUNTY PUBLIC SCHOOLS

HANOVER COUNTY PUBLIC SCHOOLS POLICY The School Board provides Workers Compensation insurance coverage at no cost to employees. This insurance program covers an injury (by accident) or illness (occupational disease) which arises out

More information

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

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

More information

Important Information about Medical Care if you have a Work-Related Injury or Illness

Important Information about Medical Care if you have a Work-Related Injury or Illness Important Information about Medical Care if you have a Work-Related Injury or Illness Complete Written Employee Notification regarding Medical Provider Network (Title 8, California Code of Regulations,

More information

What Benefits Are Available In A Georgia Workers Compensation Claim? Ty Wilson Attorney At Law 1-866-937-5454 www.tywilsonlaw.

What Benefits Are Available In A Georgia Workers Compensation Claim? Ty Wilson Attorney At Law 1-866-937-5454 www.tywilsonlaw. What Benefits Are Available In A Georgia Workers Compensation Claim? Ty Wilson Attorney At Law 1-866-937-5454 www.tywilsonlaw.com Special Report What Benefits Are Available In A Georgia Workers Compensation

More information

WORKERS COMPENSATION GUIDELINES Reporting and Processing Workers Compensation Claims

WORKERS COMPENSATION GUIDELINES Reporting and Processing Workers Compensation Claims WORKERS COMPENSATION GUIDELINES Reporting and Processing Workers Compensation Claims In the following pages you will find frequently asked questions and answers regarding the reporting and processing of

More information

Accident/Injury Reporting & Workers Compensation Programs For Employees. Administered by the Department of Environmental Health and Safety

Accident/Injury Reporting & Workers Compensation Programs For Employees. Administered by the Department of Environmental Health and Safety Accident/Injury Reporting & Workers Compensation Programs For Employees Administered by the Department of Environmental Health and Safety Revised July 1, 2011 Slippery Rock University Accident/Injury Reporting

More information

Accident/Incident & Workers Compensation. Packet

Accident/Incident & Workers Compensation. Packet Accident/Incident & Workers Compensation Packet Accident/Incident & Workers Compensation Program The following information is to assist you in completing the Accident/Incident & Workers Compensation Program

More information

WORKERS= COMPENSATION INCIDENT CHECKLIST

WORKERS= COMPENSATION INCIDENT CHECKLIST WORKERS= COMPENSATION INCIDENT CHECKLIST This checklist is to be completed by the IMMEDIATE SUPERVISOR of the injured employee. This packet is VERY TIME-SENSITIVE. All forms in the packet should be completed

More information

ADMINISTRATIVE PROCEDURE. Employee Injury/Incident/Disease Investigation and Reporting Procedures

ADMINISTRATIVE PROCEDURE. Employee Injury/Incident/Disease Investigation and Reporting Procedures ADMINISTRATIVE PROCEDURE HR121 Employee Injury/Incident/Disease Investigation and Reporting Procedures Board Received: June 23, 2014 Review Date: September 2017 Accountability: 1. Frequency of Reports

More information

ACCIDENT / INJURY REPORTING PROCEDURES FOR GEORGIA STATE UNIVERSITY

ACCIDENT / INJURY REPORTING PROCEDURES FOR GEORGIA STATE UNIVERSITY ACCIDENT / INJURY REPORTING PROCEDURES FOR GEORGIA STATE UNIVERSITY FOR ANY LIFE THREATENING EMERGENCY ** SEEK TREATMENT IMMEDIATELY THEN FOLLOW THE PROCEDURES THAT FOLLOW **LIFE THREATENING EMERGENCIES

More information

Workers Compensation. Your Guide to Handling Worker s Compensation Reporting and Filing

Workers Compensation. Your Guide to Handling Worker s Compensation Reporting and Filing Workers Compensation Your Guide to Handling Worker s Compensation Reporting and Filing Filing Worker s Compensation Claims Compensation Claims When the department is notified of an employee s work-related

More information

THE SUPERVISOR S ROLE:

THE SUPERVISOR S ROLE: THE SUPERVISOR S ROLE: Workers Compensation Information for CSU, Los Angeles Supervisors Human Resources Management (HRM) Workers Compensation Program August 16, 2010 Table of Contents Introduction..3

More information

Office of Physical Plant

Office of Physical Plant Office of Physical Plant The Pennsylvania State University Physical Plant Building University Park, PA 16802-1118 Please have the employee complete this Workers Compensation Signature Packet as soon as

More information

CENTERVILLE CSD Workers Compensation Medical Treatment Change

CENTERVILLE CSD Workers Compensation Medical Treatment Change ATTENTION ALL EMPLOYEES CENTERVILLE CSD Workers Compensation Medical Treatment Change EFFECTIVE September 1, 2010 If you are injured at work, you must immediately report the incident to your supervisor.

More information

Introduction...2. Or Occupational Disease...3. Workers Compensation Benefits...5. Prescription Processing Services...6. Payroll Procedures...

Introduction...2. Or Occupational Disease...3. Workers Compensation Benefits...5. Prescription Processing Services...6. Payroll Procedures... Table Of Contents Introduction...2 Procedures For Reporting A Work-Related Injury Or Occupational Disease...3 Workers Compensation Benefits...5 Prescription Processing Services...6 Payroll Procedures...6

More information

Workers Compensation Updates. Presented by: Brenda Hinds Pool, MSPH, CIH Occupational Health & Safety Officer

Workers Compensation Updates. Presented by: Brenda Hinds Pool, MSPH, CIH Occupational Health & Safety Officer Workers Compensation Updates Presented by: Brenda Hinds Pool, MSPH, CIH Occupational Health & Safety Officer INTRODUCTION Georgia State University s Workers Compensation Insurance is provided by the Department

More information

Workers Compensation Claims Report

Workers Compensation Claims Report Workers Compensation Claims Report Tel: (866) 402-6600 Fax: (866) 402-6601 In life-threatening situations, immediately seek medical assistance, then complete this claim form! All work-related incidents

More information

Supervisors Workers' Compensation Injury Reporting Procedure Updated January 1, 2012

Supervisors Workers' Compensation Injury Reporting Procedure Updated January 1, 2012 Supervisors Workers' Compensation Injury Reporting Procedure Updated January 1, 2012 Call for medical response immediately if the injury is serious Worry about the forms later 1. If the injury is not an

More information

YOUTH CONSULTATION SERVICE (YCS) WORKERS COMPENSATION POLICY AND PROCEDURES

YOUTH CONSULTATION SERVICE (YCS) WORKERS COMPENSATION POLICY AND PROCEDURES YOUTH CONSULTATION SERVICE (YCS) WORKERS COMPENSATION POLICY AND PROCEDURES - 1 -Revised 02/05 PHILOSOPHY STATEMENT It shall be the philosophy of Youth Consultation Service to value its employees as important

More information

1.2.1. Call ASC-HRM-WC if you have questions @ 877-372-7248 option [2] for HRM, then option [2] for Forest Service Employees.

1.2.1. Call ASC-HRM-WC if you have questions @ 877-372-7248 option [2] for HRM, then option [2] for Forest Service Employees. Incident Process for Traumatic Injuries or Occupational Disease This document addresses all work related injuries, including serious burns. This same process will be followed when an employee suffers a

More information

New Hire Notice -- Injuries Caused By Work

New Hire Notice -- Injuries Caused By Work New Hire Notice -- Injuries Caused By Work What does workers compensation cover? You may be entitled to workers' compensation benefits if you are injured or become ill because of your job. Workers' compensation

More information

COUNTY OF ALLEGHENY EMPLOYEE ACCIDENT REPORT

COUNTY OF ALLEGHENY EMPLOYEE ACCIDENT REPORT COUNTY OF ALLEGHENY EMPLOYEE ACCIDENT REPORT Revised 05/13/14 Section 1: Identification Information Completed by Employee (Supervisor should verify that information is correct.) Employee Name Last First

More information

Workers Compensation

Workers Compensation STARK COUNTY COMMISSIONERS HUMAN RESOURCES DEPARTMENT 110 CENTRAL PLAZA SOUTH SUITE 240 CANTON, OHIO 44702 Phone: 330.451.7371 Workers Compensation Supervisor Responsibilities 1) ASSIST the injured worker

More information

Register of Injuries Illness Near Miss Hazard Folder

Register of Injuries Illness Near Miss Hazard Folder Register of Injuries Illness Near Miss Hazard Folder LMPA Requirements regarding OH&S At each regular local staff meeting, OH&S is to be an agenda item. Staff are to review their Register of Injuries/Illness/Near

More information

Brigham and Women s Hospital Human Resources Policies and Procedures

Brigham and Women s Hospital Human Resources Policies and Procedures Brigham and Women s Hospital Human Resources Policies and Procedures SUBJECT: POLICY #: EMPLOYEE WORK-RELATED INJURY AND ILLNESS REPORTING HR-405 Effective Date: January 1, 2008 Revised: January 1, 2013

More information

WORKERS COMPENSATION EMPLOYEE S NOTICE OF INJURY (COMPLETE ALL ITEMS)

WORKERS COMPENSATION EMPLOYEE S NOTICE OF INJURY (COMPLETE ALL ITEMS) WORKERS COMPENSATION EMPLOYEE S NOTICE OF INJURY (COMPLETE ALL ITEMS) EMPLOYEE S NAME: (last) (first) EMPLOYEE S ADDRESS: (no.) (street) (city) (state) (zip) TELEPHONE: Home: Work: SOCIAL SECURITY NO.

More information

Report ALL on-the-job injuries to

Report ALL on-the-job injuries to 1817 N. Stewart Street, Suite 20 Carson City, NV 89706 Phone: 775-283-0040 Toll Free: 888-873-4234 Fax: 775-283-0035 Report ALL on-the-job injuries to Tri-Odyssey Risk Management Department Phone: 775-283-0040

More information

HOW TO REPORT A WORKERS COMPENSATION INJURY

HOW TO REPORT A WORKERS COMPENSATION INJURY HOW TO REPORT A WORKERS COMPENSATION INJURY 1. The employee must complete the Employee s Report of Incident and submit it to his/her supervisor within 2 hours of the incident. 2. The supervisor must complete

More information

EMPLOYEE INJURY REPORTING PROCEDURE

EMPLOYEE INJURY REPORTING PROCEDURE Updated 8/1/2014 TDY MEDICAL STAFFING, Inc. EMPLOYEE INJURY REPORTING PROCEDURE STEP 1: IS INJURY LIFE THREATENING/EMERGENCY? Call 911/go to ER if yes. STEP 2: CALL CLAIM INTO TDY 215-736-5147 STEP 3:

More information

California Workers Compensation Medical Provider Network Employee Notification & Guide

California Workers Compensation Medical Provider Network Employee Notification & Guide California Workers Compensation Medical Provider Network Employee Notification & Guide In partnership with We are pleased to introduce the California workers compensation medical provider network (MPN)

More information

MODEL POLICY TO COMPLY WITH NEW OSHA INJURY REPORTING REQUIREMENTS

MODEL POLICY TO COMPLY WITH NEW OSHA INJURY REPORTING REQUIREMENTS MODEL POLICY TO COMPLY WITH NEW OSHA INJURY REPORTING REQUIREMENTS XYZ COMPANY INCIDENT & INJURY REPORTING POLICY 1.0 Purpose It is the policy of XYZ Company (Company) that all incidents that result in

More information

Workers Compensation Informational Materials and Filing Overview

Workers Compensation Informational Materials and Filing Overview Workers Compensation Informational Materials and Filing Overview Call 911, as applicable, and/or seek medical attention as necessary. Report the incident to the supervisor/department. The supervisor/department

More information

COIDA ACCIDENT REPORTING

COIDA ACCIDENT REPORTING COMPENSATION FOR OCCUPATIONAL INJURIES & DISEASE ACT, 1993 Where the accident has caused death, unconsciousness or amputation or where the injured employee is presumed unable to work for a period of at

More information

Administrative Procedures Memorandum A4002

Administrative Procedures Memorandum A4002 Page 1 of 8 Date of Issue May 2015 Original Date of Issue September 1985 Subject References Links Contact REPORTING OF WORKPLACE INJURY/ILLNESS Workplace Safety & Insurance Act Occupational Health & Safety

More information

First Steps in the Claims Process: Insurers

First Steps in the Claims Process: Insurers First Steps in the Claims Process: Insurers First Steps - Insurers Insurer notified of injury by employer, employee or 3 rd party Contact the worker and employer within 3-days Consult with relevant parties,

More information

INSTRUCTIONS ON COMPLETING THE WORKERS COMPENSATION- FIRST REPORT OF INJURY REPORT

INSTRUCTIONS ON COMPLETING THE WORKERS COMPENSATION- FIRST REPORT OF INJURY REPORT INSTRUCTIONS ON COMPLETING THE WORKERS COMPENSATION- FIRST REPORT OF INJURY REPORT I. GENERAL SECTION : Information to be placed in this section only by County Risk Management personnel. The General section

More information

Dexter Mills, Executive Director

Dexter Mills, Executive Director Dexter Mills, Executive Director 3167 Cedartown Hwy SE Rome GA 30161 (706) 295-6189 FAX (706) 295-6098 Toll Free (GA only): 1-800-404-4149 Board of Control Bartow Bremen Calhoun Cartersville Catoosa Chattooga

More information

Worker s Compensation. What to do when an employee is injured at work.

Worker s Compensation. What to do when an employee is injured at work. Worker s Compensation What to do when an employee is injured at work. OCM BOCES is subject to New York State Worker s Compensation Law If an injury requires treatment by a medical provider, The BOCES must

More information

Work Injury Incident Report

Work Injury Incident Report This Packet Includes: 1. General Information 2. Instructions and Checklist 3. 1 General Information This is a must for each and every company or employer. This incident report thoroughly sets out the details

More information

NUMBER: HR 1.66. Workers Compensation. DATE: August 1988. REVISED: August 24, 2010. Division of Human Resources

NUMBER: HR 1.66. Workers Compensation. DATE: August 1988. REVISED: August 24, 2010. Division of Human Resources NUMBER: HR 1.66 SECTION: SUBJECT: Human Resources Workers Compensation DATE: August 1988 REVISED: August 24, 2010 Policy for: Procedure for: Authorized by: Issued by: All Campuses All Campuses Judy Owens

More information

Workers Compensation Claim Form (DWC 1) & Notice of Potential Eligibility e3301 (rev. 01/12) DWC 1 (rev. 6/10)

Workers Compensation Claim Form (DWC 1) & Notice of Potential Eligibility e3301 (rev. 01/12) DWC 1 (rev. 6/10) Workers' Compensation Claim Kit Instructions for Completing the Forms Required to Report a Work-Related Injury or Illness California Department of Human Resources Workers Compensation Program What are

More information

PERSONAL INJURY INSURANCE CLAIM FORM FOR

PERSONAL INJURY INSURANCE CLAIM FORM FOR PERSONAL INJURY INSURANCE CLAIM FORM FOR Please ensure all sections are fully completed prior to submitting your claim. Failure to complete all sections of this form may delay settlement of your claim.

More information

EMPLOYEE INCOME PROTECTION INSURANCE CLAIM FORM

EMPLOYEE INCOME PROTECTION INSURANCE CLAIM FORM Section 1 Claimant Details This form is to be completed in the event of: An insured employee being injured, or An Insured Employee suffering sickness that is covered under the company policy. Please ensure

More information

According to WCB Policy Number: POL 04-66, Learners (students) who are injured while performing on the job training may receive compensation benefits.

According to WCB Policy Number: POL 04-66, Learners (students) who are injured while performing on the job training may receive compensation benefits. University of Prince Edward Island Policy Policy No. admhrdemb0002 Revision No. 1 Policy Title (WCB) & Incident Reporting & Investigation Policy Page 1 of 5 Creation Date 01 April 2002 Version Date 20

More information

Injury Reporting Procedure

Injury Reporting Procedure Injury Reporting Procedure Your business is very important to us, and we're dedicated to providing you with the resources you need to help you be as successful as possible. Toward that end, Paychex Business

More information

Model Safety Program. Construction CORPORATE HEADQUARTERS 518 EAST BROAD STREET COLUMBUS, OHIO 43215 614.464.5000 STATEAUTO.COM

Model Safety Program. Construction CORPORATE HEADQUARTERS 518 EAST BROAD STREET COLUMBUS, OHIO 43215 614.464.5000 STATEAUTO.COM TM Model Safety Program Construction CORPORATE HEADQUARTERS 518 EAST BROAD STREET COLUMBUS, OHIO 43215 614.464.5000 STATEAUTO.COM TM Disclaimer: The information contained in this publication was obtained

More information

Short-Term Disability Income Benefit. Employee s Statement

Short-Term Disability Income Benefit. Employee s Statement Short-Term Disability Income Benefit Employee s Statement Employee s Statement Short Term Disability Income Benefits This guide contains the forms you need to apply for disability benefits and some important

More information

Worker s Compensation and Incident Reporting for Supervisors

Worker s Compensation and Incident Reporting for Supervisors Worker s Compensation and Incident Reporting for Supervisors This training session will help you to understand who is covered, how to report an accident, what the deadlines are for reporting, and what

More information

Workers Compensation

Workers Compensation Workers Compensation All work-related injuries or illnesses must be reported. If the injury is an emergency, arrange for appropriate medical treatment. The employee has the right to select his or her own

More information

Voluntary Disability Benefits

Voluntary Disability Benefits Voluntary Disability Benefits Enclosed you will find a disability packet that will provide information to assist you in filing for disability benefits through The Claremont Colleges Voluntary Disability

More information

Step 2: Verify that the location of the accident is safe and secure. Protect the site as necessary.

Step 2: Verify that the location of the accident is safe and secure. Protect the site as necessary. Supervisor's Guide to Managing On-the-Job Injuries Employee Responsibilities: Employee reports injury to employer/supervisor and seeks treatment from a BWC-certified medical provider (All providers in

More information

INSTRUCTIONS WORKER S COMPENSATION CLAIM KIT AEGIS CORPORATION - WORKER S COMPENSATION CLAIM KIT INSTRUCTIONS

INSTRUCTIONS WORKER S COMPENSATION CLAIM KIT AEGIS CORPORATION - WORKER S COMPENSATION CLAIM KIT INSTRUCTIONS CLAIM KIT INSTRUCTIONS SOFTWARE REQUIREMENTS To view, complete, and print this application, you will need Adobe Reader or Adobe Acrobat software. This product is available for free download by visiting

More information

Policy: Incident, Injury, Trauma And Illness

Policy: Incident, Injury, Trauma And Illness Policy: Rev May 15 PURPOSE Prom Coast Centres for Children (PCCC) is committed to providing a safe and healthy environment at its services, despite prevention efforts incidents, injuries and illness may

More information

Short Term Disability Income Benefit. Employee s Guide

Short Term Disability Income Benefit. Employee s Guide Short Term Disability Income Benefit Employee s Guide Short Term Disability Income Benefits This guide contains the forms you need to apply for disability benefits and some important information about

More information

All Accidents, Dangerous Occurrences, and Serious Incidents will be reported as regulated by this policy.

All Accidents, Dangerous Occurrences, and Serious Incidents will be reported as regulated by this policy. E11 Policies and Procedures Reporting of Accidents and Serious Incidents Originator: Vice President Human Resource Services & Sustainability Approver: President s Council Effective: October 21, 2014 Replaces:

More information

ACCIDENT, INJURY, AND INCIDENT REPORTING PROCEDURES

ACCIDENT, INJURY, AND INCIDENT REPORTING PROCEDURES ACCIDENT, INJURY, AND INCIDENT REPORTING PROCEDURES VEHICLE ACCIDENTS/PROPERTY DAMAGE Non-Workers Compensation Accident Report Form Attached is a sample copy of the accident report for vehicle damage,

More information

Dallas County Human Resources/Civil Service Department. Workers Compensation: Frequently Asked Questions for Managers

Dallas County Human Resources/Civil Service Department. Workers Compensation: Frequently Asked Questions for Managers Dallas County Human Resources/Civil Service Department Workers Compensation: Frequently Asked Questions for Managers Below you will find a categorical list of the most Frequently Asked Questions (FAQ s)

More information

Traumatlc injury and Claim for Continuation of Pay/Compensation

Traumatlc injury and Claim for Continuation of Pay/Compensation Federal Employee's Notice of Traumatlc injury and Claim for Continuation of Pay/Compensation U.S. Department of Labor Employment Standards Administration Office of Workers' Compensation Programs Employee

More information

Part 1 To be filled in by the worker. The following information is provided as guidance to workers filling in Part 1.

Part 1 To be filled in by the worker. The following information is provided as guidance to workers filling in Part 1. Form Workers compensation claim form Part 1 To be filled in by the worker. The following information is provided as guidance to workers filling in Part 1. Notify your employer of your injury or disease

More information

Important Information about Medical Care if you have a Work-Related Injury or Illness

Important Information about Medical Care if you have a Work-Related Injury or Illness Important Information about Medical Care if you have a Work-Related Injury or Illness Complete Written Employee Notification Re: Medical Provider Network (Title 8, California Code of Regulations, section

More information

WORKERS' COMPENSATION CLAIMANT INFORMATION PACKET

WORKERS' COMPENSATION CLAIMANT INFORMATION PACKET WORKERS' COMPENSATION CLAIMANT INFORMATION PACKET Instructions Statement of Rights Prescription ID and Pharmacy Information The New York State Insurance Fund TLC EMERGENCY MEDICAL SERVICES Inc. TLC MEDICAL

More information

An accident is an unplanned event that causes personal injury, or damage to property, product or the environment.

An accident is an unplanned event that causes personal injury, or damage to property, product or the environment. Accidents and Incidents. An accident is an unplanned event that causes personal injury, or damage to property, product or the environment. An incident is an unplanned event that could have but did not

More information

Employee Injury/Illness Reporting and Managed Return to Work. April 15, 2011 HR 23. Human Resources Responsible Key Business

Employee Injury/Illness Reporting and Managed Return to Work. April 15, 2011 HR 23. Human Resources Responsible Key Business Managed Return to Work Date Effective April 15, 2011 City Manager Revision Date Effective Code Number HR 23 Human Resources Responsible Key Business Objective: The City of Charlotte seeks to ensure the

More information

The ACCG Claims Office staff is here to help you. Please feel free to call us with your questions and concerns.

The ACCG Claims Office staff is here to help you. Please feel free to call us with your questions and concerns. 1 WELCOME This handbook contains information prepared by the Association County Commissioners of Georgia - Group Self-Insurance Workers Compensation Fund (ACCG - GSIWCF) to assist employees and management

More information

HOW TO FILE A DISABILITY CLAIM (For Benefits Provided Pursuant to an Employer Provided Benefit Plan)

HOW TO FILE A DISABILITY CLAIM (For Benefits Provided Pursuant to an Employer Provided Benefit Plan) HOW TO FILE A DISABILITY CLAIM (For Benefits Provided Pursuant to an Employer Provided Benefit Plan) If you have Short Term Disability and/or Long Term Disability coverage by virtue of your employment,

More information

Family and Medical Leave Act (FMLA)

Family and Medical Leave Act (FMLA) Family and Medical Leave Act (FMLA) FMLA is a federal law designed to balance the needs of employers and employees in circumstances when employees must take medical leave for serious medical conditions.

More information

Form Workers compensation claim form

Form Workers compensation claim form Form Workers compensation claim form Part 1 of the claim form is to be filled in by the worker. The following information is provided as guidance to workers filling in Part 1 Notify your employer of your

More information

ASU SUPERVISOR S ACCIDENT/ILLNESS INVESTIGATION FORM

ASU SUPERVISOR S ACCIDENT/ILLNESS INVESTIGATION FORM ASU SUPERVISOR S ACCIDENT/ILLNESS INVESTIGATION FORM Return to: ASU Office of Human Resources, Workers Comp Office, PO Box 32010, Human Resources Building, 330 University Hall Drive, Boone, NC 28608 This

More information

REPORTING SCHOOL ACCIDENTS SUPPORT DOCUMENT

REPORTING SCHOOL ACCIDENTS SUPPORT DOCUMENT REPORTING SCHOOL ACCIDENTS SUPPORT DOCUMENT 1. Introduction This support document outlines the purpose of school accident reports and the responsibilities of principals and school staff in relation to

More information

Employee s Report of Injury Form

Employee s Report of Injury Form Employee s Report of Injury Form Instructions: Employees shall use this form to report all work related injuries, illnesses, or near miss events (which could have caused an injury or illness) no matter

More information

ACCIDENT REPORTING FORM

ACCIDENT REPORTING FORM ACCIDNT RPRTING FRM PLAS PRINT R TYP: 1. mployee Name (Last, First, MI) 2. Home Telephone 3. Social Security Number: M P L 4. Home Address (No & Street, City, State Zip Code) 5. Marital Status 6. No. of

More information

Important Information about Medical Care if you have a Work-Related Injury or Illness

Important Information about Medical Care if you have a Work-Related Injury or Illness Important Information about Medical Care if you have a Work-Related Injury or Illness Initial Employee Written Notification Regarding Your Medical Provider Network Complete Written Employee Notification

More information

ELGIN LOCAL SCHOOLS. WORKERS COMPENSATION MANUALS AND FORMS For Elgin Administration

ELGIN LOCAL SCHOOLS. WORKERS COMPENSATION MANUALS AND FORMS For Elgin Administration ELGIN LOCAL SCHOOLS WORKERS COMPENSATION MANUALS AND FORMS For Elgin Administration Revised May 2014 1 ELGIN LOCAL SCHOOLS BUREAU OF WORKER S COMPENSATION CLAIM INSTRUCTIONS The Following steps must be

More information

Workers Compensation. Initial Procedures

Workers Compensation. Initial Procedures Workers Compensation Initial Procedures INJURY HOTLINE Available 24 hours / 7 days a week Registered Nurses Nationwide Coverage Translation Services Medical referral to designated clinic or ER Document

More information

STANISLAUS COUNTY OFFICE OF EDUCATION. Safety Department. Employee Workers Compensation Manual

STANISLAUS COUNTY OFFICE OF EDUCATION. Safety Department. Employee Workers Compensation Manual STANISLAUS COUNTY OFFICE OF EDUCATION Safety Department Employee Workers Compensation Manual T A B L E O F C O N T E N T S S E P T E M B E R 2 0 1 4 Introduction 3 Workers Compensation Defined 3 Workers

More information