Cherry Creek School District Employees
|
|
- Emerald Reeves
- 5 years ago
- Views:
Transcription
1 Office of Risk Management 4850 South Yosemite Street Greenwood Village, Colorado FAX: TO: FROM: Cherry Creek School District Employees Karyn Fast, Risk Manager Sherry Williams, Risk Management Specialist Christine Baxter, Risk and Opportunity Specialist Jody Prentice, Risk Management Specialist DATE: July 1, 2018 SUBJECT: Workers Compensation (1) Administration (2) Procedures Workers Compensation claims are administered by the Risk Management Department in the Fiscal Services Division located in the Auxiliary Services Center. All work related injury information including first reports of injury, designated physicians work status reports, notification of lost time due to a work related injury, return to work releases, any questions, can be directed to riskmanagement@cherrycreekschools.org, Sherry Williams ( ) Christine Baxter ( ), or Jody Prentice ( ). The Colorado Workers Compensation Statute is very specific on the timelines for reporting of work related injuries by the employee, as well as by the employer. Fines and penalties can be assessed for late reporting against both the employee and/or the employer. The law requires the injured employee to report the work-related injury in writing within 4 working days of the accident (see attached Employer s First Report of Injury). We must have the completed first report of injury in our third party administrator s office within 8 days of the injury and they must file it with the State Division of Workers Compensation within 20 days of the injury to admit liability or deny the claim. We have attached procedures to establish the required process for seeking medical treatment, reporting claims, statutory timelines and forms to be used for work related injuries. We have also included a Workers Compensation Program Employee Information document to assist you in the completion of the First Report of Injury form. This document should give you a general overview of how the Workers Compensation system operates. If you have questions, or if we can further assist you, please feel free to give one of us a call.
2 Cherry Creek School District Workers Compensation Program Employee Information Introduction The Colorado Workers Compensation Act (Title 8) establishes that employers, such as Cherry Creek School District, must provide medical care and a scheduled amount of Wage Loss Benefit to employees who sustain an injury or illness arising out of their employment. This obligation can be met either by purchasing insurance or by self-insuring the risk. The District has elected to self-insure this obligation through the Joint School Districts Workers Compensation Self Insurance Pool. The following are instructions for making a claim under the District s Workers Compensation Program and a brief outline of benefits. This information is not meant to be a detailed explanation of the Workers Compensation Statute. If more specific information is desired please contact the Colorado Division of Workers Compensation or the Office of Risk Management. Medical Care Medical expenses, including hospital charges, bills from designated physicians, prescriptions, etc. for work related injuries and illness are covered under the District s Workers Compensation Program. Except in cases of extreme emergency, such as life or limb threatening, medical treatment is to be obtained only from one of the medical facilities designated by the District. You may select from the five corporate medical providers listed on the provider list where you want to receive treatment for your work related injury. Follow-up care, after receiving emergency medical treatment, must be provided by one of the designated providers listed on the provider list the next day or as soon as possible. The District has designated Concentra, Concentra (Formerly US Health Works Medical Care), Care Now, Rocky Mountain Medical Group, and Workwell Occupational Medicine as the facilities for treatment of work related injuries/illnesses. An Authorization for Medical Treatment form is included that will need to be signed by the building nurse and/or your supervisor or you may use your District ID Badge. You will need to bring the form or your ID badge with you to present at the facility you have chosen from the Designated Provider List. In case of extreme emergency (life or limb threatening), or if you are outside the Denver Metropolitan Area on District related business, go immediately to the nearest emergency medical facility for treatment. Either you or your representative must contact the District s Risk Management Office, Sherry Williams ( ), Christine Baxter ( ), or Jody Prentice ( ) by the following work day to report the injury and select a provider. If any employee wishes to receive medical care for a work related injury/disease from his/her personal physician or a provider other than those that have been authorized by our insurance company, it will be at the employees own expense. Prescription Drug Program Cherry Creek Schools has partnered with Optum to have prescriptions for your work related injury filled at no expense to you. A temporary card will be provided to you at your initial doctor s visit. Authorization cards will be mailed directly to you after your claim has been filed. Simply take the authorization card, along with your prescription, to the nearest participating pharmacy. Optum will bill our Workers Compensation third party administrator directly.
3 Wage Loss Benefits Every claim is subject to a three day statutory waiting period. If you lose more than three days of work because of a work related injury or disease, you are entitled to compensation equal to two thirds (66%) of your average weekly wage subject to a maximum figure, which is established and adjusted each year by statute. The District will allow you to use up to 3 days of your accumulated sick leave days for absence due to a work-related injury, but only if the work comp doctor takes you off duty and/or restrictions do not allow for return to work. Thereafter, you will receive the Statutory Workers Compensation Benefits. In the event you are physically unable to return to the type of work you were doing with the district or in the event you sustain some permanent physical impairment, permanent disability benefits as established by the Colorado Workers Compensation Act may be payable. Mileage Reimbursement Benefits Workers Compensation will reimburse you at the statutory rate for trips to and from the doctor and/or physical therapy. Mileage reimbursement request forms are available in each school nurse s office or in the main office of each building. Reimbursement will be made by our Workers Compensation third party administrator (Sedgwick) after the required forms have been completed and furnished to their office. Claim Denials or Notice of Contest Because an employer is required to file an admission or denial of liability with the Colorado Division of Workers Compensation within a limited amount of time where more than 3 days of lost time occurs, you may receive a copy of a form from the adjuster entitled Notice of Contest. This form in most cases means that the adjuster has been unable to review the claim within the time limitations to be able to accept the claim as compensable. In most cases, you will receive an additional form admitting coverage or a letter denying the claim. If the claim is denied, you can either obtain the benefits available to you through the benefits program for medical expenses and lost time or you can request a hearing at the Division of Workers Compensation. Should a question arise concerning a claim you have filed, you can direct your questions to the Office of Risk Management or to the adjuster from Sedgwick who is handling your claim.
4 Cherry Creek School District s Designated Provider s List Concentra Concentra E. Iliff Ave Aurora, CO Phone: Hours: 8am-5pm, M-F Concentra E. Arapahoe Rd. Suite 100 Centennial, CO Phone: Hours: 8am-6pm, M-F Concentra (Formerly U.S. Healthworks Medical Group) 8200 E. Belleview, Suite 428C Greenwood Village, CO Phone: Hours: 8am 5pm, M-F Care Now Care Now 5620 E. Parker Rd Aurora, Co Phone: Hours: 8am - 8pm, M-F 8am 8 pm,saturday 8am-5pm, Sunday Rocky Mountain Medical Group Rocky Mountain Medical Group E. Mississippi Ave, Suite 120 Aurora, CO Phone: Hours: 8am - 5pm, M-F Workwell Occupational Medicine Workwell Occupational Medicine 2550 S. Parker Rd, Suite 150 Aurora, Co Phone: Hours: 8am 5 pm, M-F After Hours and Emergency Care Centennial Medical Plaza E. Arapahoe Road Centennial, CO After Hours and Emergency Room Only Phone: In case of serious injury call 911 or go to any medical facility. Follow up care needs to be provided at one of the above selected Designated Providers the following day.
5 Your Responsibilities As an employee of the District you have certain responsibilities in your Workers Compensation claim. responsibilities are as follows: Your 1. Any work related injury or disease must be reported to your supervisor or building administrator within 48 hours of the occurrence or onset of the disease. This includes those accidents that do not require medical treatment. 2. Written notice of an injury resulting from an accident must be given by you to the Risk Management Office within 4 working days after the accident. Failure by you to give this written report may result in penalties being imposed against you. 3. If requested by your supervisor, you will assist in the completion of the form entitled Employer s First Report of Injury. This form may be completed by your supervisor and/or their designee. The completed form must be sent to the District s Risk Management Office within 4 working days of the injury or onset of the disease. 4. If medical treatment is required, you should first be examined by the nearest District nurse. If further medical treatment is necessary, obtain an Authorization for Medical Treatment from the school nurse or supervisor. In accordance with Colorado Revised Statute (5) (a), you can select from the list of corporate medical providers designated by the District (Concentra, Care Now, Rocky Mountain Medical Group, Concentra (Formerly U.S. Healthworks) or Workwell Occupational Medicine) for treatment of your work related injury. Emergency life and limb threatening treatment should be obtained at the nearest medical facility and all follow-up care needs to be provided at one of the above selected designated providers the following day. 5. The physician will provide you with a copy of the treatment form, which will contain the physician s diagnosis, a release to return to work, any work restrictions, follow-up appointment dates, or time off work requirements. You must return a copy of the doctor s report to your supervisor after each doctor s visit. Subsequent follow up appointments or therapy visits should be recorded as sick/general leave absence. It is your duty and responsibility to keep your supervisor advised on your medical updates and return to work status. 6. Your claim will be adjusted by a person retained by the District s insurance pool. It will be necessary for you to cooperate fully with the adjuster, supply any information required including a signed release and attend any medical or vocational evaluations that are arranged for you. 7. All bills you receive should be forwarded to the Risk Management Office. We will forward the bills to our adjuster for review. If the claim is accepted, bills will be paid based on the Colorado Workers Compensation Fee Schedule. If the claim is denied by the adjuster, you will be required to assume responsibility for the bills yourself or to obtain coverage from your health insurance carrier. 8. If you miss more than 3 days due to a work related injury, you must complete and file with your supervisor a Leave Request Form. On the fourth day of absence, your supervisor, office manager, or terminal manager will forward a copy of this form to the Benefits Office. Leave request forms can be found in the backyard at:
6 9. You must present a written release before you return to work from the designated provider. You cannot return to work until you have a written release from the designated provider. What Should I Do If I Am Injured At Work? 1) In the case of a serious life or limb-threatening emergency, call 911 or go to any hospital/trauma center! Follow-up care is to be arranged with one of the District s designated medical providers listed: Concentra, Concentra (Formerly US Healthworks), Care Now, Rocky Mountain Medical Group, or Workwell Occupational Medicine. 2) If the injury is not a serious emergency, you must contact the designated individual at your facility, complete a First Report of Injury, have your supervisor sign it and submit it to Risk Management. If you choose to be seen by a doctor you must select one of the District s designated medical providers listed below. You are not authorized to see your personal physician for a work related injury. Any costs for care by your personal physician will not be covered by the District s Workers Compensation program. Risk Management Contacts: Sherry Williams at / Christine Baxter at /Jody Prentice or us at riskmanagement@cherrycreekschools.org The Employer s First Report of Injury must be filed through the Office of Risk Management in order for your bills to be paid through the District s Workers Compensation program. FAX the Employer s First Report of Injury to or at riskmanagement@cherrycreekschools.org. 3) You will be seen by the District s designated medical providers and be provided follow up care. Risk Management and Sedgwick will monitor your progress throughout your claim. You must select a designated provider from the list provided below: Designated Providers Concentra Concentra ( Formerly U.S. Healthworks Medical Group) Care Now Rocky Mountain Medical Group Workwell Occupational Medicine E. Iliff Ave Aurora, Co (303) Monday-Friday 8am-5pm -OR E. Belleview #428C Greenwood Village, CO (303) (Near 1-25 & Belleview) Monday Friday 8am-5pm 5620 S. Parker Rd Aurora, CO (720) Weekdays 8 am-8 pm Saturday 8am-8pm Sunday 8am-5pm E. Mississippi Ave Suite 120 Aurora, CO (303) (Near & Mississippi) Monday- Friday 8am 5pm 2550 S. Parker Rd, Suite 150 Aurora, Co (720) Monday- Friday 8am -5pm E. Arapahoe Rd Ste100 Centennial, Co (303) Monday-Friday 8am-6pm In case of serious injury call 911 or go to any medical facility. Follow up care needs to be provided at one of the above selected designated providers the following day. 4) It is your responsibility to inform the Office of Risk Management and your supervisor of your injury as well as keep your supervisor informed of any restrictions given to you by the Designated Provider. 5) Questions? Call the Office of Risk Management, Sherry Williams at , Christine Baxter at , or Jody Prentice at We will help you through your injury and get you back to work!
7 CHERRY CREEK SCHOOL DISTRICT #5 AUTHORIZATION FOR MEDICAL TREATMENT OR EVALUATION Bring this document with you to the Work Comp Provider s Facility. EMPLOYEE S NAME DATE OF BIRTH DATE I.D. VERIFIED NOTICE AND ACKNOWLEDGEMENT Cherry Creek School District is self-insured with the Joint School District Workers Compensation Self Insurance Pool in conjunction with a third party claims administrator, Sedgwick. Your employer contact is: Claims Administrator contact: Risk Management Sedgwick 4850 S. Yosemite Street P.O. Box Greenwood Village, CO Lexington, KY Karyn Fast, Risk Manager Phone: Phone: Fax: Sherry Williams, Risk Management Specialist Phone: Christine Baxter, Risk and Opportunity Specialist Phone: Jody Prentice, Risk Management Specialist Phone: Fax: riskmanagement@cherrycreekschools.org NOTICE AND SELECTION OF PROVIDERS I do not want to seek medical treatment at this time. Please put a check mark in the box below for the Designated Provider you choose to see if seeking treatment. Concentra E. Iliff Ave Aurora, Co (303) Monday-Friday 8am-5pm -OR E. Arapahoe Rd ste100 Centennial, Co (303) Monday-Friday 8am-6pm Concentra (Formerly U.S. Health Works Medical Group) 8200 E. Belleview #428C Greenwood Village, CO (303) (Near 1-25 & Belleview) Monday Friday 8am-5pm Care Now 5620 S. Parker Rd Aurora, CO (720) Weekdays 8 am-8 pm Saturday 8am-8pm Sunday 8am-5pm Rocky Mountain Medical Group E. Mississippi Ave Suite 120 Aurora, CO (303) (Near & Mississippi) Monday- Friday 8am 5pm Workwell Occupational Medicine 2550 S. Parker Rd, Suite 150 Aurora, Co (720) Monday- Friday 8am - 5pm In case of serious injury call 911 or go to any medical facility. Follow up care needs to be provided at one of the above selected designated providers the following day.
8 Signature: Date: MILEAGE REIMBURSEMENT FORM Claim Number: Name: Employer: Cherry Creek School District Address: DATE FROM DESTINATION ROUND TRIP MILES PURPOSE TOTAL MILES: I certify that the statements in the above schedule are true and correct in all respects; that payment of the amounts claimed herein has not and will not be reimbursed to me from any other sources; that travel performed for which reimbursement is claimed was performed by me for medical treatment and that no claims are included for expenses of a personal or political nature or for any other expenses not authorized by Workers Compensation; and that I actually incurred or paid the operating expense of the motor vehicle for which reimbursement is claimed on a mileage basis. I am aware that I may be prosecuted for fraud if the information I have provided is falsely documented. Signature: Date: Total to be Reimbursed: (cents) per mile = $ after 1/1/14 Return to: Sedgwick, P.O. Box 14493, Lexington, KY or Fax to
9 WARNING IF YOU ARE INJURED ON THE JOB, WRITTEN NOTICE OF YOUR INJURY MUST BE GIVEN TO YOUR EMPLOYER WITHIN FOUR WORKING DAYS AFTER THE ACCIDENT, PURSUANT TO SECTION (1) AND (1.5), COLORADO REVISED STATUTES. IF THE INJURY RESULTS FROM YOUR USE OF ALCOHOL OR CONTROLLED SUBSTANCES, YOUR WORKERS COMPENSATION DISABILITY BENEFITS MAY BE REDUCED BY ONE-HALF IN ACCORDANCE WITH SECTION , COLORADO REVISED STATUTES.
10 AVISO SI SE LASTIMA EN EL TRABAJO, DEBE DARLE UN AVISO POR ESCRITO A SU EMPLEADOR DENTRO DE CUATRO DÍAS LABORABLES DEL ACCIDENTE, SEGÚN A LA SECCIÓN DE LOS ESTATUOS REVISADOS DE COLORADO (1) Y (1.5). SI EL ACCIDENTE RESULTA DEBIDO AL USO DE ALCOHOL O UNA SUSTANCIA CONTROLADA, SUS BENEFICIOS DE LA INCAPACIDAD DE LA COMPENSACIÓN DE LOS TRABAJADORES PUEDEN SER REDUCIDOS POR UN MEDIO EN ACUERDO DE LA SECCIÓN DE LOS ESTATUOS REVISADOS DE COLORADO 8-42
Cherry Creek School District Employees
Office of Risk Management 4850 South Yosemite Street Greenwood Village, Colorado 80111 720-554-4643 FAX: 720-554-4641 TO: FROM: Cherry Creek School District Employees Karyn Fast, Risk Manager Sherry Williams,
More informationTHE EMPLOYER IS REQUIRED BY LAW TO POST THIS NOTICE
179 180 THE EMPLOYER IS REQUIRED BY LAW TO POST THIS NOTICE Colorado Employment Security Act (CESA), 8-74-101(2); Regulations Concerning Employment Security 7.3.1 through 7.3.5 NOTICE TO WORKERS You have
More informationEmployment Law Posters
Appendix C: Employment Law Posters Appendix C Employment Law Posters CDASS Program Training Manual (Revised 10/19/2017) Page 215 CDASS Program Training Manual (Revised 10/19/2017) Page 216 THE EMPLOYER
More informationLITTLETON PUBLIC SCHOOLS WORKERS COMPENSATION PROGRAM
1 LITTLETON PUBLIC SCHOOLS WORKERS COMPENSATION PROGRAM The following information explains the procedures to follow if you sustain a workers compensation injury/illness and to outline the benefits provided
More informationWorkers Compensation System Guide. NSU Employee Manual
Workers Compensation System Guide 18 NSU Employee Manual For more information regarding prevention of risk visit our website at http://www.nova.edu/risk/index.html Table of Contents Florida Guidelines
More informationSouth Dakota Workers Compensation System
An Employee s Guide to the South Dakota Workers Compensation System Division of Labor and Management 123 W. Missouri Ave. Pierre, SD 57501 Tel: 605.773.3681 sdjobs.org This booklet briefly outlines South
More informationFLORIDA TECH EMPLOYEE ACCIDENT/ INJURY REPORT
FLORIDA TECH EMPLOYEE ACCIDENT/ INJURY REPORT Contact Financial Affairs @ 674-7297 OR 8885 IMMEDIATELY regarding an Employee's Injury. Employee AND Supervisor must complete this report. EMPLOYEE INFORMATION
More informationWORKERS' COMPENSATION PROCEDURES Frequently Asked Questions
Revised November 1, 2016 WORKERS' COMPENSATION PROCEDURES Frequently Asked Questions Q. What happens if an employee is injured on the job? A. An employee should immediately report all work-related injuries,
More informationYOUR WORKERS COMPENSATION BENEFITS. Your guide to workers compensation benefits for injuries and occupational diseases. montanastatefund.
YOUR WORKERS COMPENSATION BENEFITS Your guide to workers compensation benefits for injuries and occupational diseases. montanastatefund.com I M INJURED. NOW WHAT? No one ever plans to get hurt on the job.
More informationWorkers Compensation Procedure
City and County of Denver Workers Compensation Procedure Issued September 10, 2001 Workplace Safety 201 West Colfax Avenue Dept. 1105 Denver, CO 80202 Risk.Management@Denvergov.org Workplace Safety Home
More informationWho Administers the Workers Compensation Program and Related Responsibilities?
What is Workers Compensation? Who Administers the Workers Compensation Program and Related Responsibilities? Who is Eligible for Workers Compensation? What Coverage is Provided? What is a Compensable Injury?
More informationWORKERS COMPENSATION HANDBOOK
WORKERS COMPENSATION HANDBOOK DEVELOPED BY RISK MANAGEMENT DEPARTMENT DIVISION OF BUSINESS AND FINANCE If you are injured on the job you have certain rights, benefits and responsibilities. Gwinnett County
More informationTHE CLAIMS PROCESS. Your guide to the claims experience
THE CLAIMS PROCESS Your guide to the claims experience I was injured at work, what do I do now? A quick overview of what will happen next... 1. 2. 3. 4. Report your injury The claim process starts when
More informationPART-TIME HOURLY DISABILITY PLAN QUICK FACTS AND QUICK LINKS
PART-TIME HOURLY DISABILITY PLAN QUICK FACTS AND QUICK LINKS Your Part-time Hourly Disability Option Short-term Disability A Quick Look at the Disability Plan Short-term disability When benefits begin:
More informationShould you have any questions about any aspect of the Workers' Compensation Program, you may call the UNCG Benefits Office at extension
WORKER'S COMPENSATION MEMORANDUM Scope: All University Employees [Program Governed by North Carolina General Statutes Chapter 97] Effective: September 4, 1995 Revised: December 1, 2001 TO: All University
More informationWORKERS COMPENSATION POLICIES AND PROCEDURES
WORKERS COMPENSATION POLICIES AND PROCEDURES OVERVIEW The City of Miami has a Managed Care Arrangement with AmeriSys which will provide care for job-related injuries. Medical services will be provided
More informationLee County Board of County Commissioners Workers Compensation Procedures QUICK REFERENCE GUIDE
Lee County Board of County Commissioners Workers Compensation Procedures QUICK REFERENCE GUIDE Part I IF YOU AND/OR YOUR EMPLOYEE ARE INJURED IN A WORK-RELATED ACCIDENT THAT IS NOT LIFE THREATENING, YOU
More informationEMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE GEORGIA STATE BOARD OF WORKERS' COMPENSATION
GEORGIA STATE UNIVERSITY MODIFIED WC-1 EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE GEORGIA STATE BOARD OF WORKERS' COMPENSATION Assigned Workers Compensation Claim No.: WC NOTE: FAILURE TO
More informationEMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE GEORGIA STATE BOARD OF WORKERS' COMPENSATION
GEORGIA STATE UNIVERSITY MODIFIED WC-1 EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE GEORGIA STATE BOARD OF WORKERS' COMPENSATION Assigned Workers Compensation Claim No.: WC NOTE: FAILURE TO
More informationFor faster claim payment* please submit your claim online at
Claims Made Easy For faster claim payment* please submit your claim online at www.combinedinsurance.com/claims FILING A CLAIM BY MAIL 1. Download the claim form 2. Print all six pages of the claim form
More informationWorkers Compensation Basics
Workers Compensation Basics What is work comp and what does it cover? Workers compensation coverage is an employee benefit that is mandated by law, which differs by each state, and covers employees for
More informationEMPLOYEE WORKERS COMPENSATION HANDBOOK 2018
EMPLOYEE WORKERS COMPENSATION HANDBOOK 2018 The City of Stockton is self-insured for Workers' Compensation benefits. The City pays benefits directly to injured employees, rather than purchasing an insurance
More informationFor faster claim payment* please submit your claim online at
Claims Made Easy For faster claim payment* please submit your claim online at www.combinedinsurance.com/claims FILING A CLAIM BY MAIL 1. Download the claim form 2. Print all six pages of the claim form
More informationHospital Indemnity Insurance
Hospital Indemnity Insurance Instructions for filing a Claim Follow the instructions shown below in completing/providing documentation needed to file a claim for your hospital indemnity benefits. 1. Complete
More informationPAN-AMERICAN LIFE INSURANCE COMPANY EMPLOYER ADMINISTRATIVE GUIDE FOR YOUR GROUP OCCUPATIONAL ACCIDENT PLAN
PAN-AMERICAN LIFE INSURANCE COMPANY EMPLOYER ADMINISTRATIVE GUIDE FOR YOUR GROUP OCCUPATIONAL ACCIDENT PLAN Toll Free: Phone: 855-837-1091 / Fax: 855-837-0380 1 This Administrative Guide has been provided
More informationCHUBB WORKPLACE BENEFITS A BUSINESS UNIT OF COMBINED INSURANCE COMPANY OF AMERICA, A CHUBB COMPANY INSTRUCTIONS FOR FILING CLAIMS
CHUBB WORKPLACE BENEFITS A BUSINESS UNIT OF COMBINED INSURANCE COMPANY OF AMERICA, A CHUBB COMPANY INSTRUCTIONS FOR FILING CLAIMS GETTING STARTED Follow the Claimant Instructions below to complete the
More informationWorkers Compensation Injury Instructions
Friendswood Independent School District 302 Laurel, Friendswood Texas 77546 Phone: 281-482-1267 Fax: 281-996-2606 Workers Compensation Injury Instructions The following information must be completed for
More informationA Practical Guide on How to Handle Employee Injury/Accident. Employer Manual. (HR Contacts and Supervisors only)
A Practical Guide on How to Handle Employee Injury/Accident 18 Employer Manual (HR Contacts and Supervisors only) For more information regarding prevention of risk visit our website at http://www.nova.edu/cwis/fop/risk/
More informationAccident/Incident Report For Work Related Injuries
Accident/Incident Section I: Accident Report : Name of Injured Employee: Male Female SS# XXX-XX- DOB: Location: Job Title: of Hire: Location Phone# Supervisor: Employee s home address: City/State/Zip:
More informationAccident/Incident Report For Work Related Injuries
Section I: Accident Report : Name of Injured Employee: Male Female SS# XXX-XX- DOB: of Hire: Location: Job Title: Location Phone #: Supervisor: Employee s Home Address: City/State/Zip: of Injury: _ Home
More informationWorkers Compensation Injury Packet
Workers Compensation Injury Packet This Workers Compensation Injury Packet is designed to simplify and streamline the information Managers and Employees must provide after an on the job injury. (This packet
More informationINDUSTRIAL COMMISSION OF ARIZONA
INDUSTRIAL COMMISSION OF ARIZONA WORKERS COMPENSATION INFORMATION FOR THE INJURED WORKER Phoenix Office: Industrial Commission of Arizona 800 W. Washington Street Phoenix, Arizona 85007-2922 Claims Phone:
More informationChubb Travel Protection
Chubb Travel Protection Claim Forms Table of Contents Claim Form Page Main 1 Attending Physician Statement 9 Car Rental Collision Damage 12 Accidental Death & Dismemberment 17 Chubb Travel Protection Claim
More informationMEDICAL/SICKNESS CLAIM FORM
1. PLEASE FULLY COMPLETE THIS FORM 2. ATTACH ITEMIZED BILLS 3. MAIL TO HSR E-mail: Berkley@HSRI.com HSR Plaza II 4100 Medical Parkway Carrollton, Texas 75007 Phone: (972) 512-5600 Fax: (972) 512-5820 Toll
More informationPlease send your completed form to: Claims Department P.O. Box Atlanta, Georgia 30342
** THE ATTACHED FORM IS TO BE USED IN FILING FOR DISABILITY BENEFITS ** PLEASE FOLLOW THESE INSTRUCTIONS CAREFULLY 1) The Loan Information Statement at the top of the claim form should be completed by
More informationAccident Benefits Claim Instructions
Claim Instructions Your Accident Benefit Claim This packet contains the forms necessary to apply for. Every space on these forms should be filled in to avoid delay in processing your application. If a
More informationNew 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 informationVoluntary 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 informationEDUCATOR SALARY PROTECTION PLAN DISABILITY CLAIM FORM Claim Questions: Tax Questions:
Claim Questions: 800-527-4572 Tax Questions: 800-845-2290 For use with policies issued by the following Unum [ Unum ] subsidiaries: Unum Life Insurance Company of America Provident Life and Accident Insurance
More informationNorth Carolina State Government W O R K E R S C O M P E N S A T I O N E M P L O Y E E H A N D B O O K
North Carolina State Government W O R K E R S C O M P E N S A T I O N E M P L O Y E E H A N D B O O K NORTH CAROLINA OFFICE OF STATE HUMAN RESOURCES September 2016 PURPOSE The contents in this handbook
More informationWorkers Compensation Handbook
Workers Compensation Handbook Effective 2018-19 Announcing new Workers Compensation Procedures All injured workers can call the Workers Compensation offices at 772-564-3130 or 772-564-3129 to file a claim.
More informationAccidental Death Claim Instructions
Phone : 1-877-722-1959 Fax: 443-279-2901 Accidental Death Claim Instructions The Claimant/ Insured should complete and sign the Accidental Death Insurance claim form in full and return it with the documentation
More informationWhat to Expect Whe n Yo u Ha v e A Cl a i m
10. Can I fax my claim form? Yes, we can accept faxes at 508-853-2867; we also ask that the original be sent via mail. Our fax number appears in the upper left-hand corner of our Claim Forms for your convenience.
More informationAccident, Sickness, Heart Attack/Heart Disease/Stroke Underwritten by: Humana Insurance Company Administered by: Bay Bridge Administrators LLC
Accident, Sickness, Heart Attack/Heart Disease/Stroke Underwritten by: Humana Insurance Company Administered by: Bay Bridge Administrators LLC Claim Filing Instructions Page 1 Insured s Statement of Claim:
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 informationUtah Transit Authority Personal Injury Protection Information
Utah Transit Authority Personal Injury Protection Information Revised 11/2016 A passenger on a UTA bus or a pedestrian injured by a bus may be entitled to Personal Injury Protection benefits. To claim
More informationDisability. Short-Term Disability benefits. Long-Term Disability benefits
Your plan provides you with disability coverage that gives you and your family protection against some of the financial hardships that can occur if you become disabled or injured. The benefits include:
More informationWORKERS COMPENSATION. Your safety is everyone s responsibility, especially yours PROCEDURE MANUAL
WORKERS COMPENSATION Your safety is everyone s responsibility, especially yours PROCEDURE MANUAL Risk Management Department 2016 SANTA MONICA COLLEGE EMPLOYEES IN CASE OF WORK INJURY OR ILLNESS REPORT
More informationInsured Home Telephone Number Policy Number(s) ( ) Address Social Security Number Date of Birth
For use with policies issued by the following Unum Group ( Unum ) subsidiaries: Unum Life Insurance Company of America Provident Life and Accident Insurance Company The Paul Revere Life Insurance Company
More informationDear Valued Customer:
Administered by Travel Insured International; Claims Department Dear Valued Customer: We are sorry that your travel plans were disrupted. We have attached the following checklist and claim forms that you
More informationGROUP DISABILITY CLAIM APPLICATION
GROUP DISABILITY CLAIM APPLICATION SM Short Term Disability (STD) SEND TO: P.O. BOX 9461 PORTLAND, ME 04104-5056 TEL: (888) 234-2641 FAX: (800) 293-4781 Long Term Disability (LTD) SEND TO: P.O. BOX 9461
More informationClaim Form and Instructions
What can I do to avoid delays? Missing information will delay the processing of your claim. Please be sure you: Sign and return the attached Authorization and the Certification on page 3. Complete the
More informationToll-free: Fax: Call toll-free Monday through Friday, 8 a.m. to 8 p.m. Eastern Time.
For use with policies issued by the following Unum Group [ Unum ] subsidiaries: Unum Life Insurance Company of America Provident Life and Accident Insurance Company OUR COMMITMENT TO YOU We understand
More informationHumana Insurance Company Accident, Sickness, Heart Attack/Heart Disease/Stroke Claim Filing Instructions
Humana Insurance Company Accident, Sickness, Heart Attack/Heart Disease/Stroke Claim Filing Instructions Page 1 Insured s Statement of Claim: Must be completed each time you file a claim. Be sure to answer
More informationInjured Employee Workers Compensation (WC) Packet -To be followed by the injured or ill employee-
Injured Employee Workers Compensation (WC) Packet The Injured Employee Workers Compensation (WC) Packet should be followed if you experience a work-related injury or illness. The following documents are
More informationPOLICY & PROCEDURE DOCUMENT NUMBER: Finance and Administration. Workers Compensation Program. DATE: February 6, 2006
POLICY & PROCEDURE DOCUMENT NUMBER: 4.9102 DIVISION: TITLE: Finance and Administration Workers Compensation Program DATE: February 6, 2006 REVISED: December 10, 2007, March 15, 2014 Policy for: All Employees
More informationAccident Claim form (W)
Accident Claim form (W) Policy no Claim no Full name Customer Account Number Combined Insurance seeks to pay all genuine claims. We check all claims carefully to identify fraudulent or exaggerated claims.
More informationPOLICYHOLDER / CERTIFICATEHOLDER
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 informationGroup Short-Term Disability Claim Form and Instructions
Fax to: Claims 1.800.880.9325 From: Fax Number: Date: Number of pages:_ Group Short-Term Disability Claim Form and Instructions What can I do to avoid delays? Missing information is one of the major causes
More informationULI205 Page 1 of 6. Date: Signature: Print Name:
Administrator s Office PO BOX 25326 Overland Park, Kansas 66225-5326 1-800-237-4463 Unified Life Insurance Company ACCIDENT/SICKNESS DISABILITY CLAIM FORM INSURED S PORTION Insured Name: Address: Date
More informationTEACHING PERSONNEL Policy: Temporary Paid Leaves of Absence. Sick leave may be used to extend bereavement leave.
A. Sick Leave 1. General Provisions Temporary Paid Leaves of Absence i. At the beginning of each school year, each teacher will be allocated one day of sick leave per 18 days of employment. Unused days
More informationTHIS FORM MUST BE ENTIRELY COMPLETED IN ORDER TO PROCESS YOUR CLAIM COBB COUNTY SCHOOL DISTRICT EMPLOYEE REPORT OF WORK RELATED ACCIDENT
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 informationWalgreens Company-Paid Disability Plan for Hourly Team Members
Walgreens Company-Paid Disability Plan for Hourly Team Members Summary Plan Description Prepared by the Walgreens Human Resources Department for eligible Walgreens Hourly- Paid team members This Summary
More informationPlease have the employee complete this Workers Compensation Signature Packet in addition to submission of an injury report using:
Please have the employee complete this Workers Compensation Signature Packet in addition to submission of an injury report using: Online system link located at http://ohr.psu.edu/workers-compensation/
More informationSun Life Assurance Company of Canada
Long Term Disability Claim Packet - Claimant Instructions for the Claimant Please mail all documents 4-6 weeks before the end of your elimination period. Please make sure to initiate the Long Term Disability
More informationHamilton County Board of County Commissioners WORKERS COMPENSATION POLICY
Hamilton County Board of County Commissioners SECTION 5.4: WORKERS COMPENSATION POLICY A. State law in Ohio provides that every County employee is entitled to Workers Compensation for an injury, occupational
More informationFor use with policies issued by the following UnumProvident Corporation [ UnumProvident ] subsidiaries:
CLAIM FOR INCOME PROTECTION BENEFITS Chattanooga Customer Care Center, P.O. Box 12030, Phone: 800.633.7479 Fax: 423.755.3009 For use with policies issued by the following UnumProvident Corporation [ UnumProvident
More informationAll other times, including holidays, a telephone call-in service is provided
Worldwide Financial Services Common Carrier Trip Cancellation/Trip Interruption: Worldwide Financial Services Common Carrier Trip Cancellation/Trip Interruption Insurance reimburses the actual Non-Refundable
More informationDISTRICT OF COLUMBIA Workers Compensation Key Forms and Dates
2 N. Charles Street, Baltimore, MD, 21201 / 410.752.8700 T / 410.752.6868 F / www.fandpnet.com DISTRICT OF COLUMBIA Workers Compensation Key Forms and Dates Franklin & Prokopik. All rights reserved (rev
More informationSection Eleven. Referrals and Prior Authorization REFERRAL PROCESS. Physician Referrals within Plan Network
REFERRAL PROCESS Physician Referrals within Plan Network Physicians may refer members to any Specialty Care Physician (Specialist) or ancillary provider within the Fidelis Care network. Except as noted
More informationGroup Disability Claim Filing Instructions
Claims Department P. O. Box 925 Group Disability Claim Filing Instructions IMPORTANT: All portions of this claim form must be completed after disability begins to avoid undue delay in processing claimant
More informationTopic: ON-THE-JOB INJURY AND ILLNESS POLICY. Policy #: Version: 1.2 Revision Date: 8/1/12
HUMAN RESOURCES POLICY MANUAL Topic: ON-THE-JOB INJURY AND ILLNESS POLICY Policy #: 704.00 Version: 1.2 Revision Date: 8/1/12 A. GENERAL POLICY 1. The Workers' Compensation Act of the State of Alabama
More informationNational Trust Travel Plan
National Trust Travel Plan Travel Insurance Designed for Travelers of INSURE FOR Trip Cancellation Missed Connection Baggage Loss and Delay and Emergency Medical Evacuation Early Purchase Advantages: Cancel
More informationIf your claim is denied within the first 14 days, you will not be paid any lost wage benefits.
Who is OHSU s Workers Compensation Carrier? Saif Corporation, 400 High Street, SE, Salem, OR 97312 1.800.285.8525 Who would be the OHSU contacts for employees with questions related to injury reporting
More informationPERSONAL ACCIDENT OR SICKNESS CLAIM FORM
PERSONAL ACCIDENT OR SICKNESS CLAIM FORM This form must be completed truthfully and accurately. The list of documents required is not exhaustive and we reserve our right to request from you any additional
More informationAccident Report Cover Sheet
Accident Report Cover Sheet Employee Name: Social Security #: Address: Phone Number: D.O.B.: Marital Status: Dependents: Date Employee first started working for Kaye Personnel: (not at incident site, but
More informationToll-free: Fax: Call toll-free Monday through Friday, 8 a.m. to 8 p.m. Eastern Time.
For use with policies issued by the following Unum Group [ Unum ] subsidiaries: Unum Life Insurance Company of America Provident Life and Accident Insurance Company OUR COMMITMENT TO YOU We understand
More informationALLSTATE LIFE INSURANCE COMPANY OF NEW YORK AP4 INDIVIDUAL ACCIDENT POLICY WITH OPTIONAL RIDER CLAIM FORM
ALLSTATE LIFE INSURANCE COMPANY OF NEW YORK AP4 INDIVIDUAL ACCIDENT POLICY WITH OPTIONAL RIDER CLAIM FORM If you have any questions regarding benefits available, or how to file your claim, or if you would
More informationHospital Confinement/Outpatient Surgery Claim
FAX this direction Hospital Confinement/Outpatient Surgery Claim FAX this form: 1-800-880-9325 From: Or mail: P.O. Box 100195, Columbia, SC 29202 File Your Claim Online Number of pages: u Simply log into
More informationRapid Pay Income Replacement SM Claim Form Instructions
Rapid Pay Income Replacement SM Claim Form Instructions EPIC s Rapid Pay Claim Form has three sections you (the employee), your employer, and your attending physician(s) must each complete your corresponding
More informationFor use with policies issued by the following Unum Group [ Unum ] subsidiaries:
OUR COMMITMENT TO YOU For use with policies issued by the following Unum Group [ Unum ] subsidiaries: Unum Life Insurance Company of America Provident Life and Accident Insurance Company The Paul Revere
More informationYOUR BENEFIT PLAN THE RECTOR AND VISITORS OF THE UNIVERSITY OF VIRGINIA EMPLOYER: THE RECTOR AND VISITORS OF THE UNIVERSITY OF VIRGINIA PLAN
YOUR BENEFIT PLAN THE RECTOR AND VISITORS OF THE UNIVERSITY OF VIRGINIA EMPLOYER: THE RECTOR AND VISITORS OF THE UNIVERSITY OF VIRGINIA PLAN NUMBER: 934202 PLAN EFFECTIVE DATE: January 1, 2016 BENEFITS
More informationGROUP DISABILITY CLAIM APPLICATION SEND TO:
GROUP DISABILITY CLAIM APPLICATION SM Short Term Disability (STD) SEND TO: P.O. BOX 9461 PORTLAND, ME 04104-5056 TEL: (888) 234-2641 FAX: (800) 293-4781 Long Term Disability (LTD) SEND TO: P.O. BOX 9461
More informationGroup Long Term Disability
Group Long Term Disability Life Insurance Company of rth America Connecticut General Life Insurance Company Cigna Life Insurance Company of New York Great-West Healthcare Administered by Cigna Group Long
More informationClaim Packet for Medical Treatment
Claim Packet for Medical Treatment 1-877-368-2116 ALL BLOOD BORNE PATHOGENS EXPOSURES AND REPETITIVE INJURIES (I.E. CARPAL TUNNEL) CLAIMS SHOULD BE REFERRED TO LAKESIDE MEDICAL CLINICS IF AN EMPLOYEE IS
More informationAccident Claim Package
Accident Claim Package By furnishing this form, the Company does not confirm there is insurance in force and does not waive any of its rights or defenses. CLAIMANT S STATEMENT 1. Insured s Full Name 2.
More informationVoluntary Benefits Disability Income Claim Form Claimant Initial Statement of Disability
Amalgamated Life Insurance Company Disability Benefits Claim Department P.O. Box 5453, White Plains, NY 10602-5453 Toll-Free: 1-866-975-4089 / Fax: 1-914-367-4114 Voluntary Benefits Disability Income Claim
More informationG. Workers Compensation Claim Form: The form used to report a work injury or illness to your employer.
F. Claims Adjuster: The term for insurance companies and others that handle your workers' compensation claim. Most claims adjusters work for insurance companies or third party administrators handling claims
More informationWorkers Comp 101. Geri Diaz, Esq. Camacho CalvoLaw Group
Workers Comp 101 Geri Diaz, Esq. Camacho CalvoLaw Group AGENDA Workers compensation overview Classification of claims Roles and responsibilities WC benefits Return to work issues Settlement Fraud issues
More informationAccident Claim. File Your Claim Online. Optional Service Release Agreement
Accident Claim Colonial Life ACCIDENT FAX: 1-800-880-9325 Telephone: 1-800-325-4368 FAX this direction FAX this form: 1-800-880-9325 Or mail: P.O. Box 100195, Columbia, SC 29202 From: Number of pages:
More informationDISABILITY CLAIM FORM
DISABILITY CLAIM FORM 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 at 1-800-348-4489,
More informationAmerican Claims Management P.O. Box San Diego, CA Dear Policyholder,
American Claims Management P.O. Box 85251 San Diego, CA 92186-5251 Innovative Solutions. Exceptional Results. Dear Policyholder, You have purchased Workers Compensation Insurance through Arrowhead General
More informationSun Life Assurance Company of Canada
Long Term Disability Claim Packet - Claimant Instructions for the Claimant Please mail all documents 4-6 weeks before the end of your elimination period. Please make sure to initiate the Long Term Disability
More informationWHAT YOU SHOULD KNOW WHEN YOU HAVE BEEN INJURED IN A MOTOR VEHICLE ACCIDENT
WHAT YOU SHOULD KNOW WHEN YOU HAVE BEEN INJURED IN A MOTOR VEHICLE ACCIDENT This document provides current information about obtaining assistance to meet your needs through insurance benefits and other
More informationWorkers Compensation Handbook & Guide
Workers Compensation Handbook & Guide United Business Insurance Company 350 Franklin Road, Suite 330 Marietta, GA 30067 Phone 678-766-8242 X204 www.united-business.us Dear valued client: Welcome! United
More informationSun Life Assurance Company of Canada
Sun Life Assurance Company of Canada Short Term Disability Claim Packet Instructions Send in ALL signed statements, which we require to properly review the claim. Failure to provide complete and accurate
More informationCLAIMANT RIGHTS AND RESPONSIBILITIES RULES FOR FILING A CLAIM AND APPEAL RIGHTS
DETACH THIS PAGE AND KEEP FOR YOUR RECORDS CLAIMANT RIGHTS AND RESPONSIBILITIES RULES FOR FILING A CLAIM AND APPEAL RIGHTS 1. It is your responsibility to file this claim form promptly after you stop working
More informationTravel Insurance Claim Form
What You Need To Do Before making a claim, it is important to have the following information available: 1. Your travel insurance policy number (from your Certificate of Insurance) 2. Your daytime contact
More informationWorkers 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 informationClaims and Appeals Procedures
Dear Participant: December 2002 The Department of Labor s Pension and Welfare Benefits Administration has issued new claims and appeals regulations that will be applicable to the Connecticut Carpenters
More information