Workers Compensation Guidelines
|
|
- Everett Long
- 5 years ago
- Views:
Transcription
1 Ventura County Schools Self-Funding Authority Workers Compensation Guidelines Version 1.1 August 2015 Prepared by YORK Risk Services Group, Inc.
2 Table of Contents Introduction...4 Self-funded program...4 Contacts...5 Information and Assistance Office:...6 What is Workers Compensation?...7 No-fault, mandatory coverage...7 What is not covered?...7 Eligible employees, volunteers, and ROP students...7 Workers compensation benefits...8 Medical Care... 8 Temporary Disability Benefits... 9 Permanent Disability Benefits Vocational Rehabilitation Services Supplemental Job Displacement Benefits Death Benefits Supplementing Temporary Disability Benefits...11 Overview...11 Industrial Accident Leave...11 Accrued Sick Leave and Accrued Vacation Leave...12 Extended Sick Leave Month Rehire List...13 Transitional Duty...13 Pre-Designating a Doctor...14 Employees who pre-designate...14 Employees who do not pre-designate...14 Claims Filing Responsibilities...15 Employees...15 Employers...16 Oc-Med Program...18 Injury Prevention Program...18 Denied Claims...20 Appendix A...21 August 2015 ed. VCSSFA Workers Compensation Guidelines Page 2
3 Appendix B...23 Appendix C...27 Appendix D...29 Appendix E...31 Appendix F...33 Appendix G...37 Appendix H...42 August 2015 ed. VCSSFA Workers Compensation Guidelines Page 3
4 Introduction The Ventura County Schools Self-Funding Authority (VCSSFA) is a Joint Powers Authority (JPA) that provides its member agencies with Workers Compensations coverage and services through a self-insured Workers Compensation Program. VCSSFA utilizes an outside company, YORK Risk Services Group, Inc. to administer the benefits. These guidelines were prepared by YORK Risk Services Group, Inc. to help members understand the Workers Compensation Program that VCSSFA offers and the procedures to follow when an employee is injured or becomes ill as a result of work-related activities. All members are encouraged to read this publication and share it with administrative leaders and supervisors. Self-funded program The members of VCSSFA have elected to self-fund its workers compensation liability rather than purchase an insurance policy. This means that medical bills and all other benefits are paid directly from VCSSFA Funds. Medical treatment associated with work related injuries is provided through the JPA s Medical Provider Network (MPN), WellComp. There is no insurance company involved. VCSSFA s greatest concern is to see that every employee receives the best medical care and attention available in order to ensure rapid recovery and return to work. The State of California supervises both the amount of benefits available under workers compensation and the distribution on all payments. Contacts Any questions or inquiries related to the Member Agency s workers compensation coverage through VCSSFA should be directed to the staff of the JPA. All employee questions and inquiries about workers compensation or specifically about a claim should be directed to the claims staff at YORK Risk Services Group, Inc. If an employee feels he/she needs additional information or clarification, the employee can also the State of California Division of Workers Compensation. August 2015 ed. VCSSFA Workers Compensation Guidelines Page 4
5 CONTACTS Ventura County Schools Self-Funded Authority Elizabeth Atilano, Executive Director 5189A Verdugo Way Camarillo, CA fax Coni Hernandez, Workers Compensation Consulting Services Claims Administrator YORK Risk Services Group, Inc. P.O. Box Roseville, CA fax Jody Gray, President Devora Brainard, V.P. WellComp x 225 Devora.brainard@yorkrsg.com Winston McCathan, Manager Winston.mccathan@yorkrsg.com Cheryl Hogue, Account Manager Cheryl.hogue@yorkrsg.com Dorothy Davis, Senior Claims Examiner Dorothy.davis@yorkrsg.com August 2015 ed. VCSSFA Workers Compensation Guidelines Page 5
6 Greg Bowles, Claims Examiner Rose Ramirez, MO/Future Medical Examiner Silvia Orozco, Claims Examiner Information and Assistance Office: Worker s Compensation Appeals Board 1901 N. Rice Rd Suite 200 Oxnard, CA Information and Assistance Officer Tina Urias Direct Line: Fax: August 2015 ed. VCSSFA Workers Compensation Guidelines Page 6
7 What is Workers Compensation? No-fault, mandatory coverage Workers Compensation is a state-mandated coverage in California for all eligible employees who are injured or become ill as a result of their employment. An employee could be injured in one incident while at work or through repeated exposures at work. Workers Compensation is a no-fault system, meaning that injured employees need not prove the injury was someone else's fault in order to receive workers' compensation benefits for an on-the-job injury. The workers' compensation system is based on a trade-off between employees and employers employees should promptly receive the statutory workers' compensation benefits for on-the-job injuries, and in return, the workers' compensation benefits are the exclusive remedy for injured employees against their employer. What is not covered? Typically, workers compensation does not cover injuries that occur outside of work, or are due to personal illness, self-inflicted injuries, intoxication, or personal disputes. Eligible employees, volunteers, and ROP students The VCSSFA workers compensation program applies only to the member agencies employees and substitutes, volunteers, and students in a Member Agency-authorized Regional Occupational Program (ROP) provided that the following requirements are met: Employees and Substitutes The injured or ill person must be a full-time or part-time employee i.e., registered in the Member Agency s payroll system. Contractors, consultants, vendors, and other third parties are generally covered by their own employers workers compensation program. The injury or illness must be sustained within the course and scope of the person s employment. August 2015 ed. VCSSFA Workers Compensation Guidelines Page 7
8 Volunteers and ROP Students The VCSSFA workers compensation program also covers volunteers and students in a Member Agency-authorized Regional Occupational Program (ROP) who are not paid a salary. The injury or illness must be sustained within the course or scope of the volunteer or ROP duties. For the purpose of workers' compensation coverage, a volunteer is defined as a person rendering services to the Member Agency where the Member Agency has control and direct supervisory responsibility over the manner and result of the services rendered; and the volunteer receives no remuneration for such services other than meals, transportation, lodging, or reimbursement for incidental expenses, if appropriate. Workers compensation benefits There are six basic types of workers' compensation benefits available, depending on the nature, date, and severity of the worker's injury: (1) medical care, (2) temporary disability benefits, (3) permanent disability benefits, (4) vocational rehabilitation services for injuries that occurred before January 1, 2004, (5) supplemental job displacement benefits for injuries that occurred after January 1, 2004, and (6) death benefits. Medical Care Injured workers are entitled to receive all medical care reasonably required to cure or relieve the effects of the injury, with no deductible or co-payments by the injured worker. For dates of injury on or after Jan. 1, 2004, an injured worker is limited to 24 chiropractic, 24 occupational therapy, and 24 physical therapy visits. The JPA has established a Medical Provider Network (MPN), WellComp, for the provision of all medical care and medical services related to a work related injury occurring on or after October 1, All employees, volunteers and ROP Students are covered by the MPN. However, if the employee has notified the employer in writing prior to the injury that he or she has a "personal physician" on the Personal Physician Designation form (see Appendix A), the employee may be treated by that physician from the date of injury. A personal physician for workers compensation must be a Medical Doctor (M.D.) or Doctor of Osteopathy (D.O.), or group comprised of the same who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner. Further, the personal physician must be the employee s regular physician who has previously directed the employee s medical treatment and retains the employee s medical records and August 2015 ed. VCSSFA Workers Compensation Guidelines Page 8
9 medical history. A personal physician cannot be a chiropractor or an acupuncturist. Following an injury and employee will be directed by his/her employer to an initial care provider within the WellComp MPN and can thereafter change providers by selecting another provider within the WellComp MPN. The MPN includes providers from all specialties including chiropractic medicine and acupuncture. The list of participating providers can be accessed via internet at or an employee can receive a hard-copy of the most current list of providers by contacting YORK Risk Services Group, Inc. Temporary Disability Benefits Those workers unable to return to work within three days 1 are entitled to temporary disability benefits to partially replace wages lost as a result of the injury (workers compensation benefits are generally designed to replace two-thirds of the lost wages, up to a statutory maximum). Eligibility for temporary disability benefits is determined by the authorized treating physician. An employee may not be eligible for temporary disability benefits if transitional duty is available that accommodates any temporary restrictions imposed by the treating physician. After the day of injury, eligibility for temporary disability benefits begin on the fourth calendar day the employee cannot work as authorized by the employee s treating physician within the WellComp MPN, unless a pre-approved Personal Physician Designation form is on file see Appendix A). By law, the three-day period is waived if the injury results in immediate hospitalization or the employee is off work for more than 14 days. Note that the member agency, in accordance with the Education Code and its own memorandums of understanding (MOU) will supplement temporary disability benefits so that injured workers receive full pay during Industrial Accident Leave, including the first three days following the injury. If leave extends beyond 60 working days employees are entitled to supplement the temporary disability benefits with regular sick leave, extended sick leave, and other benefits depending on their position and the Member Agency MOU. (See Supplementing Temporary Disability Benefits below) 1 California Labor Code Temporary disability indemnity is not recoverable for the first three days after the employee leaves work as a result of the injury unless temporary disability continues for more than 14 days or the employee is hospitalized as an inpatient for treatment required by the injury. August 2015 ed. VCSSFA Workers Compensation Guidelines Page 9
10 Permanent Disability Benefits Injured workers who are permanently disabled are entitled to receive permanent disability benefits. A worker who is determined to have a permanent total disability receives the temporary disability benefit for life. A worker determined to have a permanent partial disability receives partial benefits for a certain period. The length of the period is based on the worker s medical condition, date of injury, age when injured, and occupation, and loss of future earning capacity. 2 Vocational Rehabilitation Services Vocational rehabilitation services are not available for injuries on or after Jan. 1, For injuries prior to that date, injured workers who are unable to return to their former type of work are entitled to vocational rehabilitation services if these services can reasonably be expected to return the worker to suitable gainful employment. Vocational rehabilitation does not apply to injury after Jan. 1, Supplemental Job Displacement Benefits This is a nontransferable voucher for education-related retraining or skill enhancement, or both, payable to a state approved or accredited school if the worker is injured on or after Jan. 1, The employee must have suffered a permanent disability and the employer does not offer modified or alternative work. Employees injured between 1/1/2004 and 12/31/2012, the amount of the voucher varies from $4,000 to $10,000, depending on the permanent disability level. Employees injured on or after Jan. 1, 2013, the voucher amount is $6000 for all permanent disability ratings. Death Benefits In the event a worker is fatally injured, reasonable burial expenses, up to $5,000, are paid for injuries prior to 1/1/2013, and up to $10,000 for injuries on or after 1/1/2013. In addition, the worker's dependents may receive support payments for a period of time, depending on the extent of their dependency, subject to a statutory maximum. 2 See California Labor Code 4658 for the period of payment based on the percentage of disability. August 2015 ed. VCSSFA Workers Compensation Guidelines Page 10
11 Supplementing Temporary Disability Benefits Overview Temporary disability benefits are one of the six workers compensation benefits described in the previous section. Temporary disability benefits provide two-thirds of the employee s normal salary up to maximum amount determined by the State of California. Temporary disability benefits continue through the period of disability up to a maximum number of weeks according to the date of injury. Employees of public educational institutions who are subject to the California Education Code are entitled to additional benefits during a workers compensation leave that vary for each agency depending on the terms of the its MOU and on past administrative practice. However, in general, during the employee s entitlement to temporary disability, there are different types of supplemental benefits provided to the employee to increase the employee s compensation. The timeline below is an example of the continuum of supplemental benefits but will vary depending on the agency s MOU and past administrative practice. Industrial Accident Leave Sick Leave Vacation Ext. Sick Leave 39-rehire 1 st day days for classified 39 absent days employees; 5 months for months certificated employees* * Family Medical Leave Act runs concurrently (12 weeks) Industrial Accident Leave Once a claim is pending or accepted, the Member Agency continues to pay the employee a regular payroll checks during Industrial Accident Leave. Industrial Accident Leave is the 60-day period following the employee s first day of absence. YORK Risk Services Group, Inc. will reimburse the Member Agency out of the VCSSFA funds for the workers compensation temporary disability benefits included in the employee s salary. August 2015 ed. VCSSFA Workers Compensation Guidelines Page 11
12 Industrial Accident Leave applies for 60 working days for any one accident or illness during any one fiscal year, except that when an industrial accident or illness leave overlaps into the next fiscal year, the employee is entitled to only the amount of unused leave due for the same injury or illness. Industrial Accident Leave is not cumulative and begins on the first day of absence. Employees are eligible to receive Industrial Accident Leave at the beginning of the second month following their probation period. Accrued Sick Leave and Accrued Vacation Leave Once the Industrial Accident Leave has run, the Member Agency applies accrued and vested sick leave and vacation days (if applicable) to supplement temporary disability benefits in order to provide the employee with a full paycheck. The Member Agency issues the employee a full check, and YORK reimburses the Member Agency out of VCSSFA funds for the workers compensation portion. An employee, who is receiving temporary disability payments and supplemental sick leave or vacation leave benefits, is considered to be on regular pay status for purposes of application of all Member Agency personnel policies except completion of the probationary period. Extended Sick Leave If an employee is not medically able to reassume job duties after exhausting sick leave and other selected leave accruals, the employee is then eligible to receive Extended Sick Leave. Due to the substantial variations from member agency to member agency, extended sick leave will not be detailed. During the extended sick leave period, the employee is entitled to receive both the workers compensation temporary disability and the benefits the member agency are obligated to pay in accordance with its extended sick leave policy. Should the combination of benefits exceed the employee regular earnings, YORK will coordinate the payments with the member agency to avoid an overpayment. August 2015 ed. VCSSFA Workers Compensation Guidelines Page 12
13 39-Month Rehire List If the employee continues to be off work beyond the period of extended sick leave, and the employee is not placed in another position, the employee will be placed on a reemployment list for a period of 39 months. Prior to the actual termination of benefits, the member agency will engage in the interactive process to identify if the employee s disability can be accommodated pursuant to the rules and regulations promulgated by the California Department of Fair Employment and Housing (DFEHA) and the Americans With Disabilities Act (ADA). Should the member agency require assistance with this process, they can contact YORK. When available during the 39-month period, the employee shall be employed in a vacant position in the class of his or her previous job over all available candidates subject to any seniority regulations. An employee, who is on the 39-Month Rehire List, has been medically released for return to work, and who does not accept an appropriate position, will be dismissed. Transitional Duty If medically feasible, member agencies will attempt to place an injured worker who is unable to return to regular duty in a transitional work environment if it is suggested by the treating physician and can be practically accommodated by the member. Transitional Duty can consist of modification to existing job responsibilities or alternate temporary assignment that can accommodate the temporary restrictions. The JPA recognizes the need to support the recovery of employees should they suffer a work-related injury or illness or develop an occupational disease. It is well established that recovery is accelerated when the employee continues to work. Based on this principle, the JPA strongly supports appropriate return-to-work in a transitional position. Member agencies can contact YORK for ideas on how to effectively put together a transitional duty program. August 2015 ed. VCSSFA Workers Compensation Guidelines Page 13
14 Pre-Designating a Doctor If an employee completes the Personal Physician Form (Appendix A) before the injury or illness takes place, the employee can use his or her personal physician to treat the injury or illness. This is called pre-designating the employee s personal physician. Employees who pre-designate If properly filed prior to an injury, an employee may treat immediately with their personal physician for workers compensation as long as he or she is a Medical Doctor (M.D.) or Doctor of Osteopathy (D.O.), or group comprised of the same who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner. Further, the personal physician must be the employee s regular physician who has previously directed the employee s medical treatment and retains the employee s medical records and medical history. A personal physician cannot be a chiropractor or an acupuncturist. When releasing the employee to secure medical care, the member agency should provide the employee with the Treatment Authorization from found in Appendix C to provide to his or her pre-designated physician. Employees who do not pre-designate If an employee does not pre-designate a doctor, the employee is directed to an initial care provider within the WellComp MPN. Each member agency works with YORK to select an initial care provider (s). Should the agency require assistance or desire to explore adding a new provider to the MPN, they should contact YORK. Each member agency should provide an injured employee with the Treatment Authorization form found in Appendix C when referring the employee for care. After the initial medical evaluation, the employee can switch to an appropriate treating physician participating in the WellComp MPN of the employee s choice if the employee still needs medical care. The new doctor must be the appropriate specialist to treat the nature of the injury or illness. The employee can obtain assistance finding the appropriate treating physician in the WellComp Network by contacting the WellComp Patient Services Department at (800) Alternatively, the employee can select their own physician by accessing the WellComp provider directory at and requesting a hard copy of the directory by contacting YORK or the WellComp patient services Department. August 2015 ed. VCSSFA Workers Compensation Guidelines Page 14
15 Claims Filing Responsibilities Employees If an employee is hurt on the job, the employee should: 1. Report the injury to the employee s supervisor immediately. If the injury or illness developed over time, the employee must report it as soon as he or she learns that it was caused by the employee s job. 2. Get emergency treatment if needed. If it is a medical emergency, the employee should go to an emergency room right away. The employee should tell the health care provider that the injury or illness is job-related. 3. Fill out and sign the employee section of the claim form entitled Employee s Claim for Workers Compensation Benefits (see Department of Workers Compensation (DWC) Form 1 in Appendix B) and give the completed form to his or her supervisor. 4. The supervisor fills out and signs the employer portion of the claim form and directs it internally so that it gets routed to VCSSFA claims administrator, YORK Risk Services Group, Inc. a. YORK must decide within 90 days whether to accept or deny the claim. If YORK accepts the claim, it means that YORK agrees that the employee s injury is covered by workers compensation. If YORK denies the claim, the employee has the right to challenge the decision. 5. Within one working day after the employee files the claim form, YORK, on behalf of the member agency, is required by the California Labor Code to authorize medical treatment 3 up to a maximum of $10,000 while the employee s claim is being investigated following notice or service of the claim form upon the Member Agency. If YORK does not respond to a request for authorization in a timely manner as outlined in Labor Code section 4610, the employee should notify the Business Services Office or their claims contact at YORK. 6. If an employee has filed a claim, the employee can call YORK for specific questions about his or her filed workers compensation claim. 3 In accordance with the ACOEM Guidelines or any other nationally recognized medical guide established for the care of industrial injuries. August 2015 ed. VCSSFA Workers Compensation Guidelines Page 15
16 7. The employee should provide his or her supervisor with all physical therapy status sheets and work status reports. Supervisors should immediately forward this information internally based on the member agency s protocols. 8. If the employee pays a bill, the employee should photocopy the receipt and forward a copy to YORK for reimbursement. Similarly, if an injured employee receives a bill, it should be forwarded directly to YORK. 9. The employee should keep his or her supervisor informed of the status of his or her injury and claim. 10. The employee should try to schedule doctor appointments and/or physical therapy visits after work. Any doctor appointments or physical therapy treatments taken during regular work hours will result in a full day being deducted from the 60 days of Industrial Accident Leave. Employers If an employee reports an injury or illness to his or her supervisor, the employer must: 1. Obtain needed medical care for the injured employee right away. a. When an employee reports an injury on a weekday during business hours and is able to transport him or herself: 1. Complete a Treatment Authorization Form (Appendix C). 2. Refer the employee to the designated WellComp initial care provider 3. If the employee has pre-designated a personal physician and it is not an emergency, the employee should go to his or her personal physician. b. If an employee is in need of immediate medical treatment, call 911. No treatment authorization is needed. c. Provide the injured or ill worker with DWC Form 1 (Appendix B) and the WellComp Informational Pamphlet (Appendix H) directly or send them by first class mail to the employee s home. The injured or ill employee must be given the form within one business day of the employee s report of the injury. The employee completes the employee section of DWC Form 1. d. Once the employee returns the DWC 1, the employer must complete the following items: August 2015 ed. VCSSFA Workers Compensation Guidelines Page 16
17 i. Item 9 Employer: Insert your agency s official name ii. Item 10 Address: Insert your agency s official address iii. Items 11-13: Insert the applicable claim information. iv. Item 16 Signature: Sign the form. v. Item 17 Title: Insert your title. vi. Item 18 Insert your telephone number. 2. Complete the Employer s Report of Occupational Injury or Illness (Appendix D) and fax of mail to YORK. Member agencies can also report claims to YORK via their web-based reporting portal. Contact YORK for a log-in and password. 3. Mail or fax a copy of the completed Employee s Claim for Workers Compensation Benefits Form (DWC Form 1) (Appendix B) to YORK. The submission of this form does not mean that the claim is automatically accepted. 4. Report any change in an injured employee s status to YORK immediately. A change in status would be a change in lost time from work, return to work, or a physician s report recommending modified work duty. 5. Forward any physical therapy status sheets and work status reports received from the employee to YORK. 6. Work with YORK to provide the employee with transitional duty if the employee is unable to return to full duties following the injury. Member agencies should also ensure that posters giving notice of workers compensation benefits are posted in conspicuous locations. A sample poster is shown in Appendix F. YORK will also contact member agencies to secure proof of the employee s actual earnings. The member agency can provide a computerized or electronic summary of earnings or use the Wage Statement Form in Appendix E. It is important that these posting notices contain the language and information regarding use and access to the WellComp MPN. As the employer, member agency s will need to cooperate with YORK and provide them with the information necessary to investigate questionable claims and to efficiently and promptly provide the benefits to which legitimately injured employees are entitled. Should a member agency suspect that an employee or medical provider is intentionally misconstruing facts in order to get benefits that they would not otherwise be entitled, immediately notify YORK so that they can initiate a report to the proper authority for suspected Fraud. August 2015 ed. VCSSFA Workers Compensation Guidelines Page 17
18 Investigations & Sub-rosa California Code of Regulations Section 10109(a) states that in order to comply with requirements of the Labor Code and the Administrative Director's regulations, a Claims Administrator must conduct a reasonable and timely investigation upon receiving notice or knowledge of an injury or claim for a workers' compensation benefit. The Department of Insurance also requires that examiners be trained on an annual basis to identify suspected insurance fraud, making your YORK examiner the most qualified to a file for a surveillance level investigation. When your examiner refers the files on your behalf, it limits the District s exposure to possible civil claims of malicious prosecution, slander or libel due to a violation of Civil Code Section Oc-Med Program Injury Prevention Program The members of Ventura County Schools Self-Funding Authority currently participate or have the ability to utilize The OC-MED Injury Prevention Program. The goal of Injury Prevention and Management Services is to reduce injuries and their related costs for all members and to provide pre and post injury support to employees. The OC-Med Program and Ergonomic Intervention Services are designed to help provide a safe and healthy work environment, create an incentive for personal responsibility, provide cost savings and increase employee morale by potentially changing work place perceptions. The VCSSFA Risk Program Dept. administers the OC-MED Injury Prevention Program, with services provided in close coordination with approved program vendors. The goal of The OC-MED Injury Prevention Program is designed not only to reduce the costs associated with injuries and workers compensation claims, but even more significant implications for efficiency, productivity, safety and health concerns amongst employees. To bring new ideas to the workplace, meet Cal/OSHA Guidelines & Standards and to learn good safety and health practices that employees will be able to implement not only at the workplace, but in everyday life, as well. The services offered through OC-MED Injury Prevention Program vary based upon the specific needs of each referral and may include but are not limited to the below list: 1. Ergonomic Jobsite Analysis: This entails the physical therapist visiting the work site in question to examine the employee s job responsibilities, their work environment, worker techniques and related contributing issues. The purpose is to identify the various risk factors that are causing the injury or potential injury, and the associated costs, and then to provide corrective August 2015 ed. VCSSFA Workers Compensation Guidelines Page 18
19 recommendations in a comprehensive report. Finally, there will be close integration with VCSSFA Risk Program Coordinator, the provider of Ergonomic Evaluation and the Risk Manager to discuss and suggest viable changes needed for the employee. 2. Ergonomic Educational Program: On-site educational programs will cover topics to enhance a successful injury prevention and management process. For example, specific target sessions for problems relating to workplace fatigue, providing preventative stretching exercises, ergonomic team set-up, a proactive attitude in management, and introduction of the "Professional Industrial Athlete" concept to the employee. 3. Follow-up Sessions: Many of the client interventions detailed above will require closely monitored followup and subsequent on-site work site visits to ensure objective, successful results. The client interventions available in the Injury Prevention and Management portion of the OC-Med Program are designed to be initiated by both the client and VCSSFA on a Post and Pre-Injury basis. All client interventions will be scheduled and monitored by VCSSFA Risk Program Coordinator. 4. Training Sessions: On-site Group Training Programs are also available and coordinated with the Risk Program Coordinator. Training is carefully customized for the occupation and the job responsibilities of those employees being trained. A. Warm-Up Program B. Lumbar / Abdominal Core stabilization Program C. Stretching D. Materials Handling E. Maintenance, Grounds & Warehouse F. Custodial G. Para Educators H. Nutritional Services I. Office Workers J. Transportation Sample Referral and OC-MED Injury Prevention Program informational needs are found in Appendix G along with assessment follow-up forms. If you may have any questions, please contact Russ Olsen, Risk Program Coordinator for VCSSFA at Alternatively, you may to rolsen@vcoe.org. August 2015 ed. VCSSFA Workers Compensation Guidelines Page 19
20 Denied Claims If a claim is denied, YORK will confer with the member agency first and then will mail a letter to the employee s home explaining why the claim has been denied. Copies of the letter will also be sent to the Member Agency. If the employee is still disabled but it is not work related then the member agency needs to provide the employee with the regular benefits that they would be entitled to absent a work related injury. August 2015 ed. VCSSFA Workers Compensation Guidelines Page 20
21 Appendix A Personal Physician Form August 2015 ed. VCSSFA Workers Compensation Guidelines Page 21
22 August 2015 ed. VCSSFA Workers Compensation Guidelines Page 22
23 Appendix B California Department of Workers Compensation Form 1 August 2015 ed. VCSSFA Workers Compensation Guidelines Page 23
24 August 2015 ed. VCSSFA Workers Compensation Guidelines Page 24
25 August 2015 ed. VCSSFA Workers Compensation Guidelines Page 25
26 August 2015 ed. VCSSFA Workers Compensation Guidelines Page 26
27 Appendix C Treatment Authorization Form August 2015 ed. VCSSFA Workers Compensation Guidelines Page 27
28 School District Employer: Date Date of Injury: Time In Time Out Dr. Address We are sending to you for consultation (Injured Employee) (Title) and evaluation in accordance with the terms of the Workers Compensation laws. Should you find that the injured worker requires treatment, please contact York s Utilization Review Department at (951) for authorization. Department Referral (Signature) Please submit your Doctor s First Report to: YORK Risk Services Group, Inc., PO Box , Roseville, CA Please indicate below whether or not the employee will be able to engage in his/her usual and customary occupation during the time of this injury. Should the employee be temporarily disabled from said occupation, we request you provide any and all restrictions causing him/her to be unable to perform his/her usual and customary duties. The employer provides modified light duty, when feasible, until he/she can return to his/her usual and customary duties, or is declared permanent and stationary. Is working and not disabled from work. Is DISABLED UNTIL Is released to return to regular work on Is released to return to modified work on WITH RESTRICTIONS of: No pushing, pulling or lifting over 10 lbs. 15 lbs. 25 lbs. 50 lbs. lbs. No soiling or wetting of dressing and/or wound. Limited use of Right Left Arm Shoulder Hand Wrist Limited Standing Walking Sitting Stooping Bending No climbing Stairs Ladders No overhead work Sitting work only ALL MODIFIED WORK INCLUDES THE RESTRICTION OF NO SPORTS ACTIVITY. Is scheduled to return to physician on at. Anticipated duration of the MODIFIED status above is day s weeks. Physician s Signature Date August 2015 ed. VCSSFA Workers Compensation Guidelines Page 28
29 Appendix D Employer s Report of Occupational Injury or Illness August 2015 ed. VCSSFA Workers Compensation Guidelines Page 29
30 August 2015 ed. VCSSFA Workers Compensation Guidelines Page 30
31 Appendix E Wage Statement August 2015 ed. VCSSFA Workers Compensation Guidelines Page 31
32 August 2015 ed. VCSSFA Workers Compensation Guidelines Page 32
33 Appendix F Workers Compensation Notice and OSHA Safety Notice Posters August 2015 ed. VCSSFA Workers Compensation Guidelines Page 33
34 August 2015 ed. VCSSFA Workers Compensation Guidelines Page 34
35 August 2015 ed. VCSSFA Workers Compensation Guidelines Page 35
36 August 2015 ed. VCSSFA Workers Compensation Guidelines Page 36
37 Appendix G OC-Med Referral Information and Ergonomic Assessment Forms August 2015 ed. VCSSFA Workers Compensation Guidelines Page 37
38 OC-Med Injury Prevention Program Referral Information Below is information that is needed and useful in order for the OC-Med Risk Program Coordinator to schedule an Ergonomic Intervention or an Ergonomic Training Presentation. Individual Ergonomic Intervention: Name of employee Position/Job Title Job responsibilities Location Phone number and extension work, home, cell Best time to contact employee address Reason for scheduling an intervention; new workstation, remodel, new or change of position, complaints and or issues What are the issues or problems the employee believes are associated with his workstation and or job duties Pre Injury Intervention or Post Injury Intervention If Post Injury nature of injury, diagnosis, work restrictions, work status History of claims filed Urgency of the request Contact person to schedule the intervention (employee, supervisor, manager) Contact person s phone number Request of ergonomic equipment/supplies Authorization for purchase of an ergonomic equipment/supplies Employee requested ergonomic evaluation How many workstations/worksites does the employee have Has a previous ergonomic intervention been conducted Has employee been provided with ergonomic equipment/supplies through a previous intervention Has the employee requested a particular item; such as a chair, flat screen monitor, wireless headset, etc. Employee s emotional and behavioral status (perception of need) Any additional information in which the OC-Med Risk Program Coordinator and the Physical Therapist should be aware of prior to contacting the employee and conducting the evaluation Ergonomic Training Presentation for a department or a group of employees: Contact person Contact person s address, phone number and extension Department Location of the training What kind of training is needed/requested Time frame for scheduling How many employees will be in attendance Any particular ergonomic issues or problems which need to be addressed during the training program August 2015 ed. VCSSFA Workers Compensation Guidelines Page 38
39 ERGONOMICS ASSESSMENT Name: Sex: M F Height: Dominant Hand: Right Left Work hours/schedule: Commute time to work: Prevention Early Intervention Post Injury Job Title: Dept #: Phone #: #: Corrective Lenses? Yes No Supervisor: Type: Contacts Bifocals Supervisor s Overtime: Yes No Lunch/Breaks: Yes No Hours: Frequency: Date of Evaluation: Date of Hire: Job Duties: Please provide some information regarding the frequency of your work tasks using the following (please circle): Never Rarely Occasional Frequently Constantly (0-10% of the shift) (up to 33% of the shift) (34-66% of the shift) (67 100% of the shift) 1. Computer use: N R O F C 2. Numeric keypad use: N R O F C 3. Inputting info. from documents: N R O F C 4. Telephone use: N R O F C 5. Handwriting: N R O F C How often are you sitting? N R O F C August 2015 ed. VCSSFA Workers Compensation Guidelines Page 39
40 Please provide information regarding any current physical discomfort levels (optional): Never Rarely Occasional Frequently Constantly (0-10% of the shift) (up to 33% of the shift) (34-66% of the shift) (67 100% of the shift) 1. Hand/wrist discomfort: N R O F C 2. Shoulder/arm discomfort: N R O F C 3. Neck discomfort: N R O F C 4. Back discomfort: N R O F C 5. Hip/leg discomfort: N R O F C Please elaborate on areas of discomfort noted above: Please describe any non-functioning equipment (i.e. chair broken, keyboard tray not working, mouse sticks): What do you like/dislike about your workstation? Off-Work Activities: Hobbies/Recreation: Computer use at home: August 2015 ed. VCSSFA Workers Compensation Guidelines Page 40
41 Identify equipment currently used: Training Section: The employee was instructed in how to adjust the chair: Yes No N/A The employee was instructed in how to adjust the keyboard platform: Yes No N/A The employee was instructed in work pacing and rest pause techniques: Yes No N/A The employee has completed ergonomics training (classroom or online): Yes No N/A RISK FACTOR ASSESSMENT: Risk Factor Affected Areas Problems/Issues Recommendations Equipment Implementation Awkward Postures Repetition Contact Stress Environment Number of Risk Factors Before evaluation: After on-site adjustments: After install of equipt: At time of follow-up evaluation: August 2015 ed. VCSSFA Workers Compensation Guidelines Page 41
42 Appendix H WellComp MPN Informational Pamphlet August 2015 ed. VCSSFA Workers Compensation Guidelines Page 42
43 August 2015 ed. VCSSFA Workers Compensation Guidelines Page 43
44 August 2015 ed. VCSSFA Workers Compensation Guidelines Page 44
EMPLOYEE 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 informationTIME OF HIRE. Athens Administrators P.O. Box 696 Concord, CA July English Version 2014 Athens Administrators
TIME OF HIRE Athens Administrators P.O. Box 696 Concord, CA 94522-0696 www.athensadmin.com English Version 2014 Athens Administrators TABLE OF CONTENTS What is workers compensation?... 2 What are the benefits?...
More informationworkers compensation?
This pamphlet may be given to all newly hired employees in the State of California. Employers and claims administrators may use the content of this document and put their logos and additional information
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 informationRepeated exposures at work. Examples: hurting your wrist from using vibrating tools, losing your hearing because of constant loud noise.
WORKERS COMPENSATION TIME OF HIRE PAMPHLET This pamphlet, or a similar one that has been approved by the Administrative Director, must be given to all newly hired employees in the State of California.
More informationRights to Workers Compensation Benefits and How to Obtain Them. What Are The Benefits? Workers compensation benefits can include:
THE INJURED WORKER Rights to Benefits and How to Obtain Them What Is? If you get an injury or illness on the job, your employer is required by law to provide workers compensation benefits. You could get
More informationYour Workers Compensation Benefits
Your Workers Compensation Benefits CALIFORNIA This form should be given to all newly hired employees in the State of California. Its content applies to industrial injuries on or after January 1, 2013.
More informationPREDESIGNATION OF PERSONAL PHYSICIANS AND REPORTING DUTIES OF THE PRIMARY TREATING PHYSICIAN REGULATIONS
PREDESIGNATION OF PERSONAL PHYSICIANS AND REPORTING DUTIES OF THE PRIMARY TREATING PHYSICIAN REGULATIONS Title 8, California Code of Regulations Chapter 4.5. Division of Workers Compensation Subchapter
More informationNew procedure in workers compensation for pre-designation of your personal physician.
Date: To All Employees: RE: New procedure in workers compensation for pre-designation of your personal physician. As of April 19, 2004, the California Legislature enacted Senate Bill 899. This bill has
More informationCity of Albany/Water, Gas & Light. Your Group Short Term Disability Plan
City of Albany/Water, Gas & Light Your Group Short Term Disability Plan Policy No. 152208 011 Underwritten by Unum Life Insurance Company of America 2/3/2009 CERTIFICATE OF COVERAGE Unum Life Insurance
More informationLong Term Disability Claim Form Anthem Life Insurance Company Claims Center P.O. Box Atlanta, GA fax
Long Term Disability Claim Form Employer: Group No: CL /AA GA 0906 To file an application for Long Term Disability benefits, please follow the instructions below to avoid unnecessary delays. This claim
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 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 informationEMPLOYEE CLAIM PACKAGE SHORT TERM DISABILITY
EMPLOYEE CLAIM PACKAGE SHORT TERM DISABILITY Disability Benefits are intended to replace a portion of your earnings during the period of time that you are unable to work due to an illness or injury. You
More informationWorkers Compensation Program
Workers Compensation Program Colorado Special Districts Property & Liability Pool has created its own workers compensation pool. The special districts now have a more competitive option compared to the
More informationWorkers' Compensation Program
Pinellas County Schools Workers' Compensation Program Manager Information Guide Risk Management & Insurance Administration Building (727)588-6196 Fax (727)588-6541 Fax (727)588-6182 (alternative) Updated:
More informationBy Russell Uliase FEDERAL WORKERS COMPENSATION AN OVERVIEW
By FEDERAL WORKERS COMPENSATION AN OVERVIEW PART 1 If you are employed by the federal government, or work for a contractor or subcontractor of the federal government, what are your rights to compensation
More informationPenske Long-Term Disability Summary Plan Description
Penske Long-Term Disability Summary Plan Description Contents Program Highlights... 1 Coverage Available to You...1 Eligibility and Enrollment... 2 Eligibility... If You Are a New Hire... If You Transfer
More informationBenefits Handbook Date September 1, Short Term Disability Benefits Payroll Policy Marsh & McLennan Companies
Date September 1, 2018 Short Term Disability Benefits Payroll Policy Marsh & McLennan Companies Short Term Disability Benefits Payroll Policy Marsh & McLennan Companies, Inc. provides salary continuation
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 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 informationDisability Coverage. Disability benefits help protect your income if you have an illness or injury that keeps you from working.
Disability Coverage Disability benefits help protect your income if you have an illness or injury that keeps you from working. Plan Highlights If you enroll in the voluntary STD benefit, you will be eligible
More informationImportant 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 informationTable of Contents* *As an information tool, the Table of Contents includes Pre-Loss Planning and Post-Loss Implementation Chapters.
Table of Contents* *As an information tool, the Table of Contents includes Pre-Loss Planning and Post-Loss Implementation Chapters. Mastering Workers Comp Costs Volume I: Pre-Loss Planning Chapter 1: Workers
More informationArticle 11 - Sick Leave And Occupational Injury
Article 11 - Sick Leave And Occupational Injury A. Sick/Occupational Injury Sick/occupational injury time is provided to allow the necessary time off to recuperate from illness or injury. An employee on
More information1: Report all incidents/injuries to your supervisor as soon as possible, but always before leaving the premises.
Seniors and People with Disabilities State Operated Community Program Injured Worker Responsibilities & Information For work-related injuries, illnesses or incidents PLEASE READ CAREFULLY. SOCP Safety
More informationCOMPANY POLICY APPVION, INC. ACCIDENT & SICKNESS FOR BARGAINING UNIT HOURLY EMPLOYEES
COMPANY POLICY Number: 9-94-236 Effective Date: 01/01/1993 Revision: 03/01/2014 Approved: Kerry Arent Subject: APPVION, INC. ACCIDENT & SICKNESS FOR BARGAINING UNIT HOURLY EMPLOYEES I. PURPOSE: Appvion
More informationGreat-West G R O U P. Long Term Disability Income Benefits. Employee s Statement
Great-West G R O U P Long Term Disability Income Benefits Employee s Statement Employee s Statement Long Term Disability This guide explains how to apply for Long Term Disability benefits. It contains
More informationInsurance Requirements
Topics Affecting Buyers of Commercial Insurance MSP C 10/2002 Insurance Requirements in a Hard Insurance Market October, 2002 Insurance Requirements in a Hard Insurance Market If you are in the construction
More informationEmory University. Your Group Long Term Disability Plan
Emory University Your Group Long Term Disability Plan Policy No. 107388 011 Underwritten by Unum Life Insurance Company of America 5/26/2017 CERTIFICATE SECTION This is your certificate of coverage as
More informationThe Workers Compensation Minefield:
518-346-7777 All Injury Cases Workers Compensation Social Security Claims The Workers Compensation Minefield: 10 Traps To Avoid www.comp7777.com 518-346-7777 All Injury Cases Workers Compensation Social
More informationShort-Term Disability Pay Policy For Salaried Associates
Short-Term Disability Pay Policy For Salaried Associates January 1, 2010 Table of Contents Introduction 3 Important Contact Information 4 Eligibility and Enrollment 5 Associate Eligibility 5 Associate
More informationNOTE: The following language is from CLPCCD Policy 4054 titled Industrial Accident and Illness Leave (Classified).
Proposed Chabot-Las Positas Community College District Administrative Procedure AP 7343 Human Resources DRAFT as of 3/16/15 AP 7343 INDUSTRIAL ACCIDENT AND ILLNESS LEAVE References: Education Code Sections
More informationChapter 8 Disability 8.1
Chapter 8 Fast Facts STD benefits (if elected) generally continue 60% of your pre-disability pay for up to 11 weeks if you become disabled and unable to work. Once an eligible employee has been disabled
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 informationRegents of the University of Minnesota. Your Group Long Term Disability Plan
Regents of the University of Minnesota Your Group Long Term Disability Plan Policy No. 471837 002 Underwritten by Unum Life Insurance Company of America 6/6/2018 CERTIFICATE OF COVERAGE Unum Life Insurance
More informationUniversity of Maine System. Full-time Represented and Non-Represented Faculty. Short Term Disability Coverage
University of Maine System Full-time Represented and Non-Represented Faculty Short Term Disability Coverage Benefit Highlights SHORT TERM DISABILITY PLAN This short term disability plan provides financial
More informationThe Pennsylvania State University. Your Group Long Term Disability Plan
The Pennsylvania State University Your Group Long Term Disability Plan Policy No. 605923 021 Faculty/Staff/Technical Service Employees Underwritten by Unum Life Insurance Company of America 10/25/2017
More informationShort Term Disability Plan
Employee Group Benefits Sarasota County Government Short Term Disability Plan SUMMARY PLAN DESCRIPTION PLAN EFFECTIVE DATE: September 13, 2008 The plan is a self-funded benefit plan ( Plan ) providing
More informationDOUGLAS COUNTY ADMINISTRATIVE POLICIES AND PROCEDURES
DOUGLAS COUNTY ADMINISTRATIVE POLICIES AND PROCEDURES TITLE POLICY NO HR.1.10 Workers Compensation Leave Policy & Modified Duty Guidelines POLICY CUSTODIAN Human Resources Approval Date: August 21, 2016
More information(a) For the purposes of this section, the following definitions apply:
9785. Reporting Duties of the Primary Treating Physician. (a) For the purposes of this section, the following definitions apply: (1) The primary treating physician is the physician who is primarily responsible
More informationShort Term Disability
Short Term Disability Salt Lake City Corporation Plan B Full-Time Employees covered under Plan B Personal Leave Plan Disability Income Coverage: Short Term Benefits Updated & Effective March 1, 2019 YOUR
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 informationBASIC INFORMATION FOR EMPLOYEES WORKERS' COMPENSATION BENEFITS AND INSTRUCTIONS FOR FILING A CLAIM
BASIC INFORMATION FOR EMPLOYEES WORKERS' COMPENSATION BENEFITS AND INSTRUCTIONS FOR FILING A CLAIM I The Ohio Bureau of Workers' Compensation (BWC) provides employees with the following benefits for work
More informationA-1 Contract Staffing, Inc.
A-1 Contract Staffing, Inc. Class II Short Term Disability Coverage Long Term Disability Coverage Benefit Highlights SHORT TERM DISABILITY PLAN This short term disability plan provides financial protection
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 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 informationDistrict School Board of Pasco County. Your Group Disability Plan
District School Board of Pasco County Your Group Disability Plan Policy No. 68687 011 Underwritten by Unum Life Insurance Company of America 1/6/2009 CERTIFICATE OF COVERAGE Unum Life Insurance Company
More informationSUN LIFE AND HEALTH INSURANCE COMPANY (U.S.)
SUN LIFE AND HEALTH INSURANCE COMPANY (U.S.) Executive Office: Home Office: One Sun Life Executive Park 201 Townsend Street, Suite 900 Wellesley Hills, MA 02481 Lansing, MI 48933 (800) 247-6875 www.sunlife.com/us
More informationTITLE 8. Industrial Relations. Division 1. Department of Industrial Relations. Chapter 4.5. Division of Workers Compensation
TITLE 8. Industrial Relations Division 1. Department of Industrial Relations Chapter 4.5. Division of Workers Compensation Subchapter 1. Administrative Director--Administrative Rules ARTICLE 3.5 Medical
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 information3.01 Rev Page 1 of 2 POLICY ON EMPLOYEE BENEFITS PROGRAM
3.01 Rev. 03-20-2006 Page 1 of 2 POLICY ON EMPLOYEE BENEFITS PROGRAM Retirement Plans 1. Matagorda County employees are fortunate to have two mandatory retirement plans which are tax deferred. The plans
More informationShort Term Disability and Long Term Disability Insurance Plans
S U M M A R Y P L A N D E S C R I P T I O N L3 Technologies, Inc. Short Term Disability and Long Term Disability Insurance Plans Effective January 1, 2017 Table of Contents The Short Term Disability and
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 information2. Pregnancy, childbirth, and recovery (Education Code 45193)
AR 4261.1(a) Classified employees employed five days a week are entitled to 12 days' leave of absence with full pay for personal illness or injury (sick leave) per fiscal year. Employees who work less
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 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 informationGadsden County School Board. Your Group Disability Plan
Gadsden County School Board Your Group Disability Plan Policy No. 66943 011 Underwritten by Unum Life Insurance Company of America 6/15/2009 CERTIFICATE OF COVERAGE Unum Life Insurance Company of America
More informationMidAmerican Energy Company
MidAmerican Energy Company HomeServices of America Employees Administrative Services for Short Term Disability Plan Benefit Highlights SHORT TERM DISABILITY PLAN This short term disability plan is provided
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 informationShort-Term Disability
Effective January 1, 2012 Short-Term Disability Experis Policy Number: GP-307243 CONSULTANT SHORT TERM DISABILITY PLAN 1 Short-Term Disability (STD) How Your Short Term Disability Coverage Works...3 How
More informationLPL Financial (herein called the Policyholder)
In Consideration of the Application for this Policy made by The Lincoln National Life Insurance Company A Stock Company Home Office Location: Fort Wayne, Indiana Group Insurance Service Office: 8801 Indian
More informationShort-Term Disability. Summary Plan Description
Short-Term Disability Summary Plan Description August 2016 Table of Contents INTRODUCTION... 1 ELIGIBILITY AND ENROLLMENT... 1 Eligibility... 1 Enrollment... 1 STD BENEFITS... 2 DURATION OF BENEFIT PAYMENTS...
More informationCounty of Dane A Municipal Corporation. Your Group Disability Plan
County of Dane A Municipal Corporation Your Group Disability Plan Policy No. 567797 011 Underwritten by Unum Life Insurance Company of America 12/5/2007 CERTIFICATE OF COVERAGE Unum Life Insurance Company
More informationShort Term Disability Income Benefits. Great-West G R O U P. Employee s Statement
Great-West G R O U P Short Term Disability Income Benefits Employee s Statement The Great-West Life Assurance Company ( Great-West Life ), all rights reserved. Any modification of this document without
More informationPlan Member Statement
Plan Member Statement Long Term Disability Claim Waiver of Premium Claim for: Basic Life Benefit AD&D Benefit An incomplete form may result in delays in the adjudication of your disability claim. Please
More informationWorkers Compensation Guidebook
Workers Compensation Guidebook Western New York Council on Occupational Safety and Health This Guidebook is for informational purposes only, and does not constitute legal advice (or create an attorney-client
More informationWage Continuation. School District of Philadelphia. Short-Term Disability Insurance Summary Plan Description
School District of Philadelphia Human Resources Office of Employee Benefits Wage Continuation Short-Term Disability Insurance Summary Plan Description K:\9250 Employee Benefits Management\Wage Continuation\CASA
More informationTHE GEORGE WASHINGTON UNIVERSITY CERTIFICATE SHORT TERM DISABILITY INCOME BENEFIT PROGRAM
THE GEORGE WASHINGTON UNIVERSITY CERTIFICATE SHORT TERM DISABILITY INCOME BENEFIT PROGRAM The George Washington University has established a short term disability (STD) income benefit Program and agreed
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 informationEmployee Group Benefits UNDERWRITTEN BY SUN LIFE ASSURANCE COMPANY OF CANADA. Oak Harbor Freight Lines, Inc.
Employee Group Benefits UNDERWRITTEN BY SUN LIFE ASSURANCE COMPANY OF CANADA Oak Harbor Freight Lines, Inc. GROUP POLICY NUMBER - 11492 POLICY EFFECTIVE DATE - December 1, 2008 POLICY AMENDMENT DATE -
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 informationDefinitions for Key Terms can be found on page 4
THIS IS A STATEMENT OF COVERAGE FOR THE LA SIERRA UNIVERSITY CALIFORNIA VOLUNTARY PLAN. THE PROVISIONS OF THIS STATEMENT APPLY TO DISABILITY AND PAID FAMILY LEAVE BENEFIT PERIODS BEGINNING ON OR AFTER
More informationSALARIED DISABILITY PLAN QUICK FACTS AND QUICK LINKS
SALARIED DISABILITY PLAN QUICK FACTS AND QUICK LINKS Your Salaried Disability Coverage 1 Short-term Disability 2 Long-term Disability A Quick Look at the Disability Plans Salaried associates automatically
More informationThe Long-Term Disability Plan
The Long-Term Disability Plan JPMorgan Chase recognizes how important income replacement can be to you and your family if you become seriously ill or injured and you can t work. The Long-Term Disability
More informationJanuary 1, Short Term Disability MMC
January 1, 2009 MMC Marsh & McLennan Companies, Inc. ( MMC ) provides salary continuation to eligible employees based on a percentage of their base salary for a period of up to twenty six (26) weeks during
More informationMultnomah County Oregon. Your Group Life Insurance Plan
Multnomah County Oregon Your Group Life Insurance Plan Identification No. 387790 015 Underwritten by Unum Life Insurance Company of America 12/27/2013 CERTIFICATE OF COVERAGE Unum Life Insurance Company
More informationBenefits Handbook Date November 1, Short Term Disability Benefits Policy Marsh & McLennan Companies
Date November 1, 2014 Short Term Disability Benefits Policy Marsh & McLennan Companies Short Term Disability Benefits Policy Marsh & McLennan Companies, Inc. provides salary continuation through the STD
More informationEmployee Group Benefits UNDERWRITTEN BY SUN LIFE ASSURANCE COMPANY OF CANADA. City of South Lake Tahoe
Employee Group Benefits UNDERWRITTEN BY SUN LIFE ASSURANCE COMPANY OF CANADA City of South Lake Tahoe Short Term Disability and Long Term Disability Insurance GROUP POLICY NUMBER - 85331 POLICY EFFECTIVE
More informationGuide. to Recovery Under The Illinois Workers Compensation Act. The Injured Employee s
The Injured Employee s Guide to Recovery Under The Illinois Workers Compensation Act Prepared By: Romanucci & Blandin, LLC 33 North LaSalle Street, 20th Floor Chicago, Illinois 60602 Toll Free: 888.458.1145
More informationForest River, Inc. Your Group Long Term Disability Plan
Forest River, Inc. Your Group Long Term Disability Plan Policy No. 951840 011 Underwritten by Unum Life Insurance Company of America 3/2/2016 CERTIFICATE OF COVERAGE Unum Life Insurance Company of America
More informationDisability Benefits Summary Plan Description for Mid-Atlantic Associates AA-S-ST/LT /13
Disability Benefits Summary Plan Description for Mid-Atlantic Associates AA-S-ST/LT--58566-1/13 Contents Your Disability Benefits... 1 About This SPD... 1 Verizon Benefits Center... 2 Changes to the Plans...
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 informationYOUR GROUP VOLUNTARY LONG-TERM DISABILITY BENEFITS. City of Tuscaloosa
YOUR GROUP VOLUNTARY LONG-TERM DISABILITY BENEFITS City of Tuscaloosa Effective October 1, 2009 HOW TO OBTAIN PLAN BENEFITS To obtain benefits see the Payment of Claims provision. Forward your completed
More informationCorporate Policies and Procedures
REV. 1 of 5 POLICY STATMENT: The County of Renfrew provides income protection through a short-term disability plan for periods of up to seventeen (17) weeks, per incident. PROCEDURE: 1. All full-time employees
More informationR LTD-0%-A. Michigan
GROUP INSURANCE POLICY NON-PARTICIPATING POLICYHOLDER: DEMONSTRATION COMPANY 032408 POLICY NUMBER: R0067363 LTD-0%-A POLICY EFFECTIVE DATE: February 1, 2008 POLICY ANNIVERSARY DATE: February 1 GOVERNING
More information500.2 Group Insurances The College currently offers life, medical, and disability insurances to eligible full-time regular employees.
Allegheny College PERSONNEL POLICIES & BENEFITS HANDBOOK Subject: EMPLOYEE BENEFITS 500 POLICY NUMBER 9/01/02 EFFECTIVE DATE 500 Employee Benefits While it is expected that the benefit plans described
More informationWorkers' Compensation Packet. This packet contains forms that must be used when completing a Workers' Compensation claim.
2017-2018 Workers' Compensation Packet August 31, 2017 This packet contains forms that must be used when completing a Workers' Compensation claim. Please throw away the previous packet. Richmond City Public
More informationBenefits. Long-Term Disability KPERS. Kansas Public Employees Retirement System. Summary Plan Description GLD 2006
Long-Term Disability Benefits Kansas Public Employees Retirement System Summary Plan Description GLD 2006 KPERS 2 Plan Sponsor Kansas Public Employees Retirement System 611 S. Kansas Ave., Suite 100 Topeka,
More informationHome Office: Chicago, Illinois Administrative Office: Philadelphia, Pennsylvania
Home Office: Chicago, Illinois Administrative Office: Philadelphia, Pennsylvania POLICYHOLDER: Roscommon Area Schools POLICY NUMBER: STD 162257 EFFECTIVE DATE: March 1, 2012 ANNIVERSARY DATES: March 1,
More informationNOTICE: NEVADA WORKERS COMPENSATION
TICE: NEVADA WORKERS COMPENSATION This business operates under Nevada Workers Compensation Law. WORKERS MUST REPORT ALL ACCIDENTS IMMEDIATELY TO THE EMPLOYER BY ADVISING THE EMPLOYER PERSONALLY, OR AN
More informationA SUPERVISOR'S GUIDE TO WORKERS' COMPENSATION DEPARTMENT OF ADMINISTRATIVE SERVICES
A SUPERVISOR'S GUIDE TO WORKERS' COMPENSATION DEPARTMENT OF ADMINISTRATIVE SERVICES THE DIVISON OF RISK MANAGEMENT SERVICES AND KEY RISK MANAGEMENT SERVICES UPDATED JANUARY 2007 TO ALL STATE OF GEORGIA
More information1. What do I do if I am injured at work or when I am on a Temporary Duty Assignment (TDY)?
Federal Employees Compensation Act FAQS for Employees 1. What do I do if I am injured at work or when I am on a Temporary Duty Assignment (TDY)? If you are injured at work, you may be entitled to injury
More informationROCHESTER INSTITUTE OF TECHNOLOGY Sick/Personal Leave and Short-Term Disability
ROCHESTER INSTITUTE OF TECHNOLOGY Sick/Personal Leave and Short-Term Disability Table of Contents Introduction...3 Important Note About Passwords...3 Sick/Personal Leave for Nonexempt Staff...3 Staff Employees
More informationCITGO Petroleum Corporation Long Term Disability Program for Salaried Employees Summary Plan Description
CITGO Petroleum Corporation Long Term Disability Program for Salaried Employees Summary Plan Description as in effect January 1, 2013 TABLE OF CONTENTS PURPOSE... 1 ELIGIBILITY... 2 Who is Eligible...
More informationA Worker's Guide to Workers Compensation From The Law Office of Robert M. Keefe
Get What You Deserve A Worker's Guide to Workers Compensation From The Law Office of Robert M. Keefe Copyright Robert M. Keefe 2010 Pg. 1 General Information, Not Legal Advice Information contained in
More informationGroup Life. Disability Benefit Forms
Unum Life Insurance Company of America First Unum Life Insurance Company Provident Life and Accident Insurance Company Provident Life and Casualty Insurance Company The Paul Revere Insurance Company Group
More informationMaricopa County Group Short-Term Disability Plan Description
Maricopa County Group Short-Term Disability Plan Description Effective July 1, 2011 Revision 03/14/11 TABLE OF CONTENTS PLAN DESCRIPTION 3 What is short-term disability (STD)? 3 Who is eligible to purchase
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 informationFirst Unum Life Insurance Company
First Unum Life Insurance Company Wagner College Your Group Disability Plan Policy No. 879348 012 Underwritten by First Unum Life Insurance Company 2/26/2016 CERTIFICATE OF COVERAGE First Unum Life Insurance
More information