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) 748-3821 or the AmTrust at (866) 272-9267 for additional information. Claim Reporting Information AmTrust North America P.O. Box 740042 Atlanta, GA 30374-0042 (866) 272-9267 phone (877) 669-9140 fax amtrustclaims@qrm- inc.com
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.
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
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.
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.