WORKER'S COMPENSATION PEMBERTON TOWNSHIP SCHOOLS FIRST REPORT EMPLOYEE INJURY/TREATMENT FORM
|
|
- Gwen Cole
- 8 years ago
- Views:
Transcription
1 WORKER'S COMPENSATION PEMBERTON TOWNSHIP SCHOOLS FIRST REPORT EMPLOYEE INJURY/TREATMENT FORM Per District Policy 8440, all work related injuries must be reported to the Nurse or Jim Flanagan (609) Ext 1014 within 24 hours Call to report an after normal hours injury TO BE COMPLETED BY INJURED WORKER: Name: Address: Date of Birth Home Number: Cell Number Job Title: Date of Injury: Time: AM or PM Supervisor: Location (Bldg) of Injury: Supervisor/Nurse to whom you reported injury: Explain what you were doing when the injury occurred / What caused the injury: Describe your injuries related to this incident: Have you had this injury at anytime in the past? Explain: Was the injury caused by another person? Circle One: Yes No If yes, please circle one: Staff Student Visitor Please circle: Intentional or Accidental List Name of Witness: Signature of Injured Worker: Page 1 Date:
2 WORKER'S COMPENSATION TO BE COMPLETED BY TREATING NURSE: Injuries Reported: Treatment Provided: Witness Form Received: Yes: No: N/A: Date form received from Injured Worker: Disposition: RTW: W/C Dr: Emergency Room: Nurse's Signature: Date: TO BE COMPLETED BY INJURED WORKER: By Signature below I affirm that I have been offered and refused the following at this time: Medical Treatment by School Nurse Medical Treatment by Approved Physician I recognize that if I would like to receive medical treatment for this injury at a future time, I must contact the nurse or Jim Flanagan in order to obtain the proper paperwork for an appointment. Employee's Signature: Date: APPROVED PHYSICIANS: Appointment Virtua at Work 101 Burrs Road, Building 2, Suite A Only Phone Number: Fax Number: Westampton, NJ Mon thru Fri 8am to 5pm Concentra Walk In Phone Number: East Gate Drive, Suite 1B Fax Number: Mount Laurel, NJ Mon thru Fri 7:30am to 5pm TO BE COMPLETED BY WORKER'S COMPENSATION COORDINATOR: SSN: DOH: Full Time: Part Time: Salary: Address of School/Department: Staff Start Time: Staff End Time: Page 2
3 Pemberton Township Schools INJURY WITNESS REPORT Your Name Home# Cell# Address: City State: Zip Name of Injured Party Date of Witnessed Injury Time: Exact Location (School & Area) Did You Witness the Injury to the Above Named Party? Yes No Explain in detail what the above party was doing when the injury occurred/ What caused the injury What injuries appeared to be sustained by the injured party? I certify that this witness report has been read and completed to the best of my ability and that all information submitted is true. Dated Signature
4 Warning 34: Workers Compensation fraud; criminal and civil penalties, a crime of the fourth degree if the person purposely or knowingly: (1) Makes, when making a claim for benefits pursuant to R.S. 34:15-1 et seq., a false or misleading statement, representation or submission concerning any fact that is material to that claim for the purpose of wrongfully obtaining the benefits; (2) Makes a false or misleading statement, representation or submission, including a misclassification of employees, or engages in a deceptive leasing practice, for the purpose of evading the full payment of benefits or premiums pursuant to R.S. 34:15-1 et seq; or (3) Coerces, solicits or encourages, or employs or contracts with a person to coerce, solicit or encourage, any individual to make a false or misleading statement, representation or submission concerning any fact that is material to a claim for benefits or the payment of benefits or premiums, pursuant to R.S. 34:15-1 et seq. for the purpose of wrongfully obtaining the benefits or of evading the full payment of the benefits or premiums. Page 4
5 INJURY REPORTING PROCEDURES EFFECTIVE July 1, 2014 General Procedure: If you are injured while on the job, you must report the incident to your supervisor or the school nurse and call Jim Flanagan at ext 1014 even if you do not wish to see a doctor. No medical payments will be made without obtaining a Provider Referral to take with you when you go for medical treatment. Normal Operating Hours: See your supervisor or school nurse. Fill out a First Report of Injury Form. Ask for an Employee s Authorization for Medical Attention and Provider Referral form if you wish to see a doctor. Wait for your supervisor or school nurse to report the claim and make the doctor appointment. After Normal Operating Hours (evenings and weekends): If you do not want to see a doctor, fill out a First Report of Injury form with your supervisor or school nurse as soon as possible. If you need medical assistance, notify your supervisor or a district representative, and then call to report the injury and receive instructions for medical treatment. Emergency Situations (Emergencies that are life and/or limb threatening): If you require emergency care, go to the nearest emergency room and have them call to report your injury. Have someone report the injury to your supervisor or a district representative as soon as possible. Note: A provider referral card will be available in the Night-time Injury Report packet in the Custodian s office. Take this referral with you After Normal Operating Hours or if possible in Emergency situations. Designated District Supervisors: James Jefferson Buildings and Grounds/Custodial Injuries Timothy Pirolli Food Service Injuries Mike Press Transportation Injuries John Swanson District Wide Reporting
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 informationSupervisors 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 informationLong Term Disability Insurance Conversion Plan
Long Term Disability Insurance Conversion Plan The Prudential Insurance Company of America INST-A002112-A Long Term Disability Insurance Conversion Plan If you have any questions regarding the conversion
More informationCentral 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 informationWorkers 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 informationAccident Claim Form. (Not to be used if you are filing a disability claim)
Fax to: Claims 1.800.880.9325 From: No#of pages: Or Mail to: P.O. Box 100195 Columbia SC 29202-3195 Accident Claim Form (Not to be used if you are filing a disability claim) Please be sure to send the
More informationEMPLOYEE HANDBOOK FOR WORKERS COMPENSATION FLORIDA
EMPLOYEE HANDBOOK FOR WORKERS COMPENSATION FLORIDA District School Board of Pasco County Kurt S. Browning, Superintendent Dear Employee: The District School Board of Pasco County s (District) goal is to
More informationDISABILITY CLAIM FORM
ACE American Insurance Company PROOF OF LOSS Mail to: ACE American Insurance Company Name of Group: UNIVERSITY OF CALIFORNIA P.O. Box 15417 Wilmington, DE 19850 800-336-0627 or 302-476-6194 Policy Number:
More informationTEXAS 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 informationNOTIFICATION OF INJURY
NOTIFICATION OF INJURY This Notification of Injury Form is to be used for accident medical claims. **Note: The SAI claim form (Parts A & B) should be submitted to Loomis (address on next page) as soon
More informationGROUP LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS INSTRUCTIONS FOR FILING A LIFE CLAIM
GROUP LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS PLEASE SUBMIT THE FOLLOWING: INSTRUCTIONS FOR FILING A LIFE CLAIM 1. THE CLAIM FORM (PAGE 2) FULLY COMPLETED BY THE EMPLOYER
More informationGROUP LIFE INSURANCE CLAIM PACKET (Death)
GROUP LIFE INSURANCE CLAIM PACKET (Death) You Can Help Ensure A Quick Claim Decision All required claim forms must be signed, dated and completed fully and accurately. Provide all supporting documentation
More informationEmployee Guidelines for Workers Compensation Accidents
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
More informationA Transitional Work Program benefits employees in several ways:
Workmen s Compensation Policy Number: 7390 Effective Date: All employees of Snake River School District 52 are covered by Workmen's Compensation insurance for bodily injury, disease, or death caused by
More informationAccident insurance plain claim form
The Lincoln National Life Insurance Company PO Box 82087, Lincoln, NE 68501-2087 toll free (800) 423-2765 Fax (877) 843-3950 www.lincolnfinancial.com Accident insurance plain claim form Policy Holder Information
More informationMay 29, 2015. Dear Injured Camper or Staff Member and Family:
May 29, 2015 Dear Injured Camper or Staff Member and Family: We are sorry to hear that you sustained an accidental injury or an unexpected illness at one of our camps. The following pages contain the claim
More informationEMPLOYEE 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 informationINSTRUCTIONS FOR FILING A CLAIM FOR DISABILITY BENEFITS
For Assistance Contact: Benefit Services of Hawaii P.O. Box 840 Honolulu, HI 96808-0840 Telephone (808) 538-8900 Fax (808) 538-8930 INSTRUCTIONS FOR FILING A CLAIM FOR DISABILITY BENEFITS Benefits Underwritten
More informationProvided By Touchstone Consulting Group Workers Compensation Employer Penalties
Provided By Touchstone Consulting Group Workers Compensation Employer New Jersey s workers compensation laws determine the benefits available to employees who are injured in the course and scope of employment.
More informationAPPLICATION FOR BENEFITS LAW ENFORCEMENT OFFICERS AND FIRE FIGHTERS DISABILITY BENEFITS TRUST FUND
EXHIBIT A M S Attorney General s Office Use Only: Application #: Receipt Date: G Approved G Disapproved Claim type: G Law Enforcement Officer G Fire Fighter STOP. Please read the fund policies and procedures
More informationAct Now! GIVE YOUR FAMILY PEAK PROTECTION. Group Long Term Disability Insurance Conversion Plan Enrollment Kit
Act Now! You must apply within 60 days of termination GIVE YOUR FAMILY PEAK PROTECTION Group Long Term Disability Insurance Conversion Plan Enrollment Kit Customer Service Center 888-262-6873 Monday through
More informationGroup/Association - Total and Permanent Disability / Waiver of Premium
Group/Association - Total and Permanent Disability / Waiver of Premium Connecticut General Life Insurance Company Life Insurance Company of rth America CIGNA Life Insurance Company of New York FRAUD WARNING:
More informationPOLICYHOLDER. Policy No.(s): Waiver of Premium (include life policies) Routine Pregnancy
CLAIM FORM AND INSTRUCTIONS If you have any questions regarding our determination of your claim, or if you would like to appeal any determination, please contact our Customer Care Center at 1-800-348-4489
More informationEMPLOYEE HANDBOOK FOR WORKERS COMPENSATION MARSHALL PUBLIC SCHOOLS MISSOURI
EMPLOYEE HANDBOOK FOR WORKERS COMPENSATION MARSHALL PUBLIC SCHOOLS MISSOURI District School Board of Marshall Public Schools Dr. Carol Maher, Superintendent Dear Employee: The District School Board of
More informationShort-Term Disability Claim Form
Short-Term Disability Claim Form Mutual of Omaha Insurance Company United of Omaha Life Insurance Company S-1 Group Disability Management Services Mutual of Omaha Plaza Omaha, NE 68175-0001 800-877-5176
More informationEmployer: Employee: Date of Loss: File Number: State Case Num:
, Claim Department Office Employer: Employee: Date of Loss: File Number: State Case Num: For compensable Workers' Compensation claims, your employer provides medical care through its Workers Compensation
More informationNAME (First, Middle, Last) Social Security Number Date of Accident (Month-Day-Year) Time of Accident
FIRST REPORT OF INJURY OR ILLNESS RECEIVED BY CLAIMS-HANDLING ENTITY SENT TO DIVISION DATE DIVISION RECEIVED DATE FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION For assistance
More informationApplication for Registration or Renewal of Athlete Agent
11 F0091 OFFICE OF THE MISSISSIPPI SECRETARY OF STATE Post Office Box 136, Jackson, MS 39205-0136 (601)359-9055 Application for Registration or Renewal of Athlete Agent A Certificate of Registration or
More informationHospital Confinement/Outpatient Surgery Claim
FAX this direction If your name has changed, attach a copy of your driver s license or other legal documentation. Hospital Confinement/Outpatient Surgery Claim FAX this form: 1-800-880-9325 Or mail: P.O.
More informationEmployee s Report of Incident and the Supervisor's Investigation
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 informationSuperintendent 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 informationNATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY NATIONWIDE SPECIALTY INSURANCE CLAIM FORM
NATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY NATIONWIDE SPECIALTY INSURANCE CLAIM FORM THIS CLAIM CANNOT BE PROCESSED WITHOUT ALL OF THE BELOW INFORMATION AND STATEMENTS OF PAYMENTS FROM
More informationTraumatlc 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 informationUnited of Omaha Life Insurance Company Group Life Claims Mutual of Omaha Plaza Omaha, NE 68175-0001 Toll Free (800) 775-8805 Fax (402) 997-1835
United of Omaha Life Insurance Company Group Life Claims Mutual of Omaha Plaza Omaha, NE 68175-0001 Toll Free (800) 775-8805 Fax (402) 997-1835 Instructions for Filing a Group Life Waiver of Premium Claim
More informationCONTINUATION OF GROUP TERM LIFE INSURANCE AND ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE EMPLOYER INSTRUCTIONS
CONTINUATION OF GROUP TERM LIFE INSURANCE AND ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE EMPLOYER INSTRUCTIONS Employees who have either terminated or lost coverage have 31 days from either their termination
More informationAccident Claim Filing Instructions
Accident Claim Filing Instructions Page One Filing Instructions Complete the appropriate sections of the claim form (page 2) Attach an itemized billing from your provider which includes the date of service,
More informationA Guide for Successfully Completing the Group Short Term Disability Claim Form
A Guide for Successfully Completing the Group Short Term Disability Claim Form Mutual of Omaha appreciates the opportunity to provide you with valuable income protection. We rely on the information you
More informationApplication for Limited Professional Liability Coverage Insured Paramedical Employee
Application for Limited Professional Liability Coverage Insured Paramedical Employee ProAssurance Indemnity Company, Inc. 1242 East Independence Street, Suite 100 Springfield, MO 65804 417.887.3120 800.492.7212
More informationWorkers 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 informationHome Office Use Only. Section B TYPE OF CLAIM: FIRST CLAIM CONTINUED CLAIM
Home Office Use Only CLAIM FORM AND INSTRUCTIONS If you have any questions regarding our determination of your claim, or if you would like to appeal any determination, please contact our Customer Care
More informationNOTIFICATION OF INJURY
NOTIFICATION OF INJURY This Notification of Injury Form is to be used for accident medical claims. Policies With Excess Coverage Eligible covered expenses will be paid only if they are in excess of other
More informationOn behalf of our company, we wish to express our sincere condolences on your loss.
Administrative Office: Valley Forge Pennsylvania 19493 Phone: 1-866-227-0379 Dear Claimant, On behalf of our company, we wish to express our sincere condolences on your loss. We hope that we may assist
More informationWe thank you for your business, and look forward to providing you with the necessary protection and care for your business and employees.
RE: Workers Compensation Claims Kit Welcome to the Workers Compensation Insurance Program offered through Tower Group Companies. While we hope that your company never has to experience a workers compensation
More informationPOLICYHOLDER / CERTIFICATEHOLDER. Policy Number(s): 1) 2) Social Security Number: Date of Birth: / / Male Female
CLAIM FORM AND INSTRUCTIONS If you have any questions regarding our determination of your claim, or if you would like to appeal any determination, please contact our Customer Care Center at 1-800-348-4489
More informationACCIDENTAL DEATH AND DISMEMBERMENT CLAIM FORM IMPORTANT INSTRUCTIONS FOR COMPLETING THE CLAIM FORM
ACCIDENTAL DEATH AND DISMEMBERMENT CLAIM FORM IMPORTANT INSTRUCTIONS FOR COMPLETING THE CLAIM FORM To ensure expeditious claim processing, the attached claim forms need to be fully completed and the following
More information225 Long Avenue Hillside, NJ 07205 Phone: (973) 923-1433 Fax: (973) 923-1311 www.ccccunion.org
PROVIDER APPLICATION FORM FOR FAMILY CHILD CARE REGISTRATION 225 Long Avenue Hillside, NJ 07205 Phone: (973) 923-1433 Fax: (973) 923-1311 www.ccccunion.org Please print all information. Attach additional
More informationVOLUNTEER APPLICATION. IMPORTANT NOTE! You MUST be at least 18 years old to work directly with the animals but there are ways for everyone to help.
VOLUNTEER APPLICATION Father John s Animal House IMPORTANT NOTE! You MUST be at least 18 years old to work directly with the animals but there are ways for everyone to help. In order to become a volunteer
More informationNATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY NATIONWIDE SPECIALTY INSURANCE CLAIM FORM INSTRUCTIONS
NATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY NATIONWIDE SPECIALTY INSURANCE CLAIM FORM INSTRUCTIONS THIS CLAIM CANNOT BE PROCESSED WITHOUT ALL OF THE BELOW INFORMATION AND STATEMENTS OF
More informationPOLICYHOLDER. 4. Date of Birth: / / Age: Social Security Number: Male Female MO/DAY/YR. Policy No.(s):
CLAIM FORM AND INSTRUCTIONS If you have any questions regarding benefits available, or how to file your claim, or if you would like to appeal any determination, please contact our Customer Care Center
More informationINSTRUCTIONS FOR FILING GROUP VOLUNTARY STD / LTD / WAIVER OF PREMIUM CLAIMS
CLAIM FORM AND INSTRUCTIONS If you have any questions regarding our determination of your claim, or if you would like to appeal any determination, please contact our Customer Care Center at 1-800-348-4489
More informationWORKERS' COMPENSATION - FIRST REPORT OF INJURY OR ILLNESS
WORKERS' COMPENSATION - FIRST REPORT OF INJURY OR ILLNESS EMPLOYER (NAME & ADDRESS INCL ZIP) CARRIER / ADMINISTRATOR CLAIM NUMBER * REPORT PURPOSE CODE * JURISDICTION * JURISDICTION LOG NUMBER * INSURED
More informationTHIS CLAIM FORM MUST BE FILED WITHIN NINETY DAYS OF ACCIDENT/OCCURRENCE OR YOU MAY FORFEIT YOUR RIGHTS PURSUANT TO N.J.S.A. 59:1 ET SEQ.
THIS CLAIM FORM MUST BE FILED WITHIN NINETY DAYS OF ACCIDENT/OCCURRENCE OR YOU MAY FORFEIT YOUR RIGHTS PURSUANT TO N.J.S.A. 59:1 ET SEQ. 1) CLAIMAINT INFORMATION DATE OF ACCIDENT $ AMOUNT OF CLAIM LAST
More informationAMERICAN NATIONAL INSURANCE COMPANY CREDIT INSURANCE DIVISION P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 800-899-6502
P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 DISABILITY CLAIM FORM INSTRUCTIONS Enclosed is a claim form required in order to process disability payments on your loan. It is important that all questions
More informationACCIDENT 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 informationWorkers' 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 informationWorkers Compensation. Presented by: Sarah L. Stoker, M.S. Coordinator II, Equal Employment Opportunity & Risk Administration March 27, 2014
Workers Compensation Presented by: Sarah L. Stoker, M.S. Coordinator II, Equal Employment Opportunity & Risk Administration March 27, 2014 What is Workers Compensation? Workers Compensation pays medical
More informationSCHOOL 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 informationHow To Get A Car Insurance Claim Form
ACCIDENTAL INJURY / SICKNESS CLAIM FORM Servicing is provided for the following companies: Conseco Insurance Company Conseco Health Insurance Company Conseco Life Insurance Company Washington National
More informationSun Life Assurance Company of Canada
Sun Life Assurance Company of Canada Long Term Disability Claim Packet - Employer Instructions for the Plan Administrator Please call our Customer Service Center at 1-800- 247-6875 from 8 a.m. to 8 p.m.
More informationCENTERVILLE 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 informationWORKERS= 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 informationLife Insurance Benefits Application Instructions
Application Instructions Please Read Carefully The application for life insurance benefits consists of the forms included in this packet, as well as the additional information noted under item 1 below.
More informationApplication for Coverage Ancillary This application is for claims made coverage. Please read the policy carefully.
I. Employer Information Agency/Broker: Address: Application for Coverage Ancillary This application is for claims made coverage. Please read the policy carefully. Name of Employer Office Address Street
More informationColonial Life & Accident Insurance Company, Columbia, SC DISABILITY FAX: 1-800-880-9325 Telephone: 1-800-325-4368.
Disability Claim FAX this direction FAX this form: 1-800-880-9325 Or mail: P.O. Box 100195, Columbia, SC 29202 From: Number of pages: Optional Service Release Agreement Please indicate below for optional
More information1. Full Name (last, first, middle initial) 2. Social Security Number 3. Phone Number (include area code)
GROUP SHORT-TERM DISABILITY STATEMENT OF EMPLOYEE (BENEFITS MAY BE DELAYED IF CLAIM FORM IS NOT FULLY COMPLETED) Please sign this page and the authorization on page two of this form to avoid delays in
More informationImportant Information
16 An Employee s Guide to the South Dakota Workers Compensation System Division of Labor and Management Phone: (605) 773-3681 www.sdjobs.org Department of Labor and Regulation 700 Governors Drive Pierre,
More informationA Guide for Successfully Completing the Group Short-Term Disability Claim Form
A Guide for Successfully Completing the Group Short-Term Disability Claim Form Mutual of Omaha appreciates the opportunity to provide you with valuable income protection. We rely on the information you
More informationAMERICAN NATIONAL INSURANCE COMPANY CREDIT INSURANCE DIVISION P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 800-899-6502
P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 CREDIT LIFE CLAIM FORM INSTRUCTIONS Enclosed is a form required to process a claim for credit life benefits. It is important that all questions be fully
More informationWORKERS COMPENSATION - FIRST REPORT OF INJURY OR ILLNESS
WORKERS COMPENSATION - FIRST REPORT OF INJURY OR ILLNESS EMPLOYER (NAME & ADDRESS INCL ZIP) CARRIER / ADMINISTRATOR CLAIM NUMBER * REPORT PURPOSE CODE * JURISDICTION * JURISDICTION LOG NUMBER * INSURED
More informationSun Life Assurance Company of Canada
Sun Life Assurance Company of Canada Long Term Disability Claim Packet - Employer Instructions for the Plan Administrator Please call our Customer Service Center at 1-800- 247-6875 from 8 a.m. to 8 p.m.
More informationLeaders Life Insurance Accident Claim Filing Instructions
Leaders Life Insurance Accident Claim Filing Instructions Page One Filing Instructions: Complete the appropriate sections of the claim form (page 2) Attach an itemized billing from your provider which
More informationGroup Term Life Insurance Continuation Form
Group Term Life Insurance Continuation Form Employees must be actively at work at the time of employment termination or retirement in order to be eligible for the continuation plan. Coverage terminates
More informationDISABILITY INCOME/OFFICE OVERHEAD EXPENSE CLAIM INSTRUCTIONS (PLEASE KEEP THIS NOTICE FOR FUTURE REFERENCE)
DISABILITY INCOME/OFFICE OVERHEAD EXPENSE CLAIM INSTRUCTIONS (PLEASE KEEP THIS NOTICE FOR FUTURE REFERENCE) Please answer all questions on the Member s Statement of your Disability Income/Office Overhead
More informationDisability Benefit Claim Form
Transamerica Worksite Marketing P.O. Box 8043 Little Rock, AR 72203-8043 Phone: 800-251-7254 (7:00 a.m. 5:00 p.m. CST) Fax: 866-586-6528 Disability Benefit Claim Form Instructions to submit claim 1) The
More informationNOTIFICATION OF INJURY
NOTIFICATION OF INJURY This Notification of Injury Form is to be used for accident medical claims. Policies With Excess Coverage Eligible covered expenses will be paid only if they are in excess of other
More informationThe forms must be completed by a qualified person and signed with their occupational title as per its respective form.
Your ability to work and generate income is your greatest asset. If a disability ever left you unable to work, a combination of increased expenses and loss of income could create financial difficulties.
More informationPOLICYHOLDER / CERTIFICATEHOLDER. Policy Number(s): 1) 2) Social Security Number: Date of Birth: / / Male Female
CLAIM FORM AND INSTRUCTIONS If you have any questions regarding benefits available, or how to file your claim, or if you would like to appeal any determination, please contact our Customer Care Center
More informationInjury 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 informationINSTRUCTIONS FOR FILING GROUP VOLUNTARY STD / LTD / WAIVER OF PREMIUM CLAIMS
CLAIM FORM AND INSTRUCTIONS If you have any questions regarding benefits available, or how to file your claim, or if you would like to appeal any determination, please contact our Customer Care Center
More informationA Guide for Successfully Completing the Group Short-Term Disability Claim Form
A Guide for Successfully Completing the Group Short-Term Disability Claim Form Mutual of Omaha appreciates the opportunity to provide you with valuable income protection. We rely on the information you
More informationA Guide for Successfully Completing the Group Short-Term Disability Claim Form
A Guide for Successfully Completing the Group Short-Term Disability Claim Form Mutual of Omaha appreciates the opportunity to provide you with valuable income protection. We rely on the information you
More informationMadison 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 informationNew Jersey Small Employer Certification
Oxford Health Insurance, Inc. New Jersey Small Employer Certification Mailing Address: NJ Small Group Enrollment Dept. 14 Central Park Drive Hookset, NH 03106 800-385-9088 For a Group Health Benefits Plan
More informationFiling a Critical Illness Claim - Correctly!
CRITICAL ILLNESS INSTRUCTIONS FOR FILING CLAIMS Dear Policyholder: Thank you for choosing USAble Life to provide your critical illness protection. We have included these instructions to assist you in the
More informationFirst Name MI Last. Street Address (P.O. Boxes cannot be accepted) City State Zip. First Name MI Last
Accident Claim Form Instructions for Filing a Claim LIFESECURE INSURANCE COMPANY ADMINISTRATIVE OFFICE ATTN: Claims Department PO Box 13490, Pensacola, FL 32591-3490 1-888-575-8246 Please have all sections
More information(to be shown on policy declarations page) City State Zip
Clubs/Groups & Special Event Insurance Request for Quote Instructions to obtain a Quote: 1. Complete form entirely to receive a quote. If the form is not completed, additional information will have to
More informationMonumental Life Insurance Company
Insurance Claim Filing Instructions PROOF OF LOSS CONSISTS OF THE FOLLOWING: 1. A completed and signed Claim form and Attending Physician s Statement. 2. For Hospital/Intensive Care/Hospital Services Coverage
More informationCity of Los Angeles Disability Insurance Claim Packet Instructions
Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for disability benefits. It also addresses common questions about Disability claims. Please save
More informationVictims Compensation Assistance Program Short Form
Pennsylvania Commission on Crime and Delinquency Office of Victims Services Victims Compensation Assistance Program Mailing Address: Street Address: Phone and Fax Numbers: P.O. Box 1167 3101 North Front
More informationEMPLOYMENT PRACTICES LIABILITY INSURANCE MAINFORM APPLICATION
EMPLOYMENT PRACTICES LIABILITY INSURANCE MAINFORM APPLICATION THIS IS AN APPLICATION FOR A POLICY THAT IS WRITTEN ON A CLAIMS-MADE BASIS AND COVERS ONLY CLAIMS FIRST MADE AGAINST THE INSUREDS DURING THE
More informationUniversity 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 informationDisability Claim Form
Disability Claim Form Fax to: 1.866.887.6644 From: Number of pages: Please be sure to send the following Information: A fully completed physician s section, A fully completed employer s section, A signed
More informationCLAIM FORM FOR LIFE INSURANCE PROCEEDS
New York Life Insurance Company Group Membership Association Claims PO Box 30782 Tampa FL 33630-3782 Dear Beneficiary: Please accept our condolences on your recent loss. We understand this is a difficult
More informationASU 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 informationNew Hire Submission and Return Receipt PLEASE SUBMIT FORMS TO: SERVICE@ADVANCEDPEO.COM OR FAX 1-866-611-9598
1933 E EDGEWOOD DR SUITE 102 LAKELAND, FL 33803 1-877-518-2881 WWW.ADVANCEDPEO.COM New Hire Submission and Return Receipt PLEASE SUBMIT FORMS TO: SERVICE@ADVANCEDPEO.COM OR FAX 1-866-611-9598 Notice to
More informationAllied Health Professional Liability Insurance Application Form
Allied Health Professional Liability Insurance Application Form With your fully completed, signed and dated application, you must submit the following information: 1. Current insurance policy declarations
More informationHumana short-term income protection claim form
Humana short-term income protection claim form 1-866-836-6144 Instructions Please read and follow the instructions carefully. 1. If this is the initial claim for benefit payments for this disability, please
More informationFirst Name MI Last Name. Relationship to Employee Employee Spouse Child Other. Date of Accident (m m d d yyyy) First Name MI Last Name
Group Accidental Injury Claim Form (Use for employee/member and dependent injury claims) Group Insurance Please send the completed form and all attachments to: The Prudential Insurance Company of America
More informationPlease have the employee complete this Workers Compensation Signature Packet upon submission of an injury report using:
Please have the employee complete this Workers Compensation Signature Packet upon submission of an injury report using: Online system link located at http://ohr.psu.edu/workers-compensation/ or Call Center
More informationMCG, Inc. dba Georgia Regents Medical Center Life Insurance Benefits Application Instructions
Application Instructions Please Read Carefully The application for life insurance benefits consists of the forms included in this packet, as well as the additional information noted under item 1 below.
More information