THIS FORM MUST BE ENTIRELY COMPLETED IN ORDER TO PROCESS YOUR CLAIM COBB COUNTY SCHOOL DISTRICT EMPLOYEE REPORT OF WORK RELATED ACCIDENT
|
|
- Erick Allison
- 6 years ago
- Views:
Transcription
1 THIS FORM MUST BE ENTIRELY COMPLETED IN ORDER TO PROCESS YOUR CLAIM COBB COUNTY SCHOOL DISTRICT EMPLOYEE REPORT OF WORK RELATED ACCIDENT (770) FOR WORKERS COMPENSATION (678) Office Fax Employee SS# DOB Age Sex Home Address City State Zip Tel# School/Dept. Employee Occupation Accident Date Time Date Reported Accident Location Body Part(s) Injured Describe the Accident (Indicate Left and Right) Witnesses Tel# *ATTENTION: IF MEDICAL TREATMENT IS SOUGHT IT MUST BE WITH AN APPROVED PANEL PHYSICIAN* Medical Treatment? Yes No Name of Treating Doctor/Clinic: Taken via Ambulance? Yes No Left Work Due to Injury? Yes No First Day Out of Work Primary Care Physician Name Tel# Prior Medical Treatment? Have you had prior injury or condition to injured body part(s) Yes No If yes, explain How Can Future Accidents Be Prevented? (Mark all that apply) Employee Training Proper Use of Equipment Improve Task Procedures Improve Work Area Equipment Correction Removal of Hazard Use of Personal Protective Equipment Provide Hazard Warning Enforce Policy/Rule Other Explain: Employee suggestion(s) for preventing similar accidents: Supervisor suggestion(s) for preventing similar incidents: Employee s Signature Date Supervisor s Signature Tel# Date NOTE: CONTACT RISK MANAGEMENT IMMEDIATELY IF MEDICAL TREATMENT IS REQUIRED. PLEASE SUBMIT SIGNED SUPERVISOR S REPORT AND THE SIGNED MEDICAL RELEASE WITHIN 48 HOURS. Please maintain a copy of this form for your records. Thank you. Revised 7/2015
2 Cobb County School District Risk Management Department Office (770) Fax (678) MEDICAL RELEASE AUTHORIZATION FORM Please submit signed medical release form, as well as the Employee Report of Work Related Accident, to the Risk Management Department within 48 hours of injury. Keep a copy for your site files. Release of Medical Information: I authorize the release to my employer and Workers Compensation Company all records relevant to my disability and my claim for disability or Workers Compensation benefits, including, but not limited to, medical diagnosis, prognosis, treatment and periods of hospitalization. It is understood that the Risk Management Department will use the information to verify my disability and determine my eligibility of appropriate benefits. This authorization applies to physicians and other health care providers, hospitals, clinics, insurance companies, Workers Compensation carriers and organizations administering benefit programs. This authorization will remain in effect throughout my claim for Workers Compensation benefits. A photocopy of this authorization will be as valid as the original. Panel of Physicians: I have received a copy of the Bill of Rights for the Injured Worker, as well as, the Traditional Panel of Physicians. Employee s Signature Date Please Print Name 7/2015
3 (This notice must be posted in a conspicuous place readily accessible to the employee at all times) OFFICIAL NOTICE TRADITIONAL PANEL OF PHYSICIANS This business operates under the Georgia Workers Compensation Law WORKERS MUST REPORT ALL ACCIDENTS IMMEDIATELY TO THE EMPLOYER BY ADVISING THE EMPLOYER PERSONALLY, AN AGENT, REPRESENTATIVE, BOSS, SUPERVISOR OR FOREMAN. If a worker is injured at work, the employer shall pay medical and rehabilitation expenses within the limits of the law. In some cases the employer will also pay a part of the worker s lost wages. Work injuries and occupational diseases should be reported in writing whenever possible. The worker may lose the right to receive compensation if an accident is not reported within 30 days (see O.C.G.A ). The employer will supply free of charge, upon request, a form for reporting accidents and will also furnish, free of charge, information about workers compensation. The employer will also furnish to the employee, upon request, copies of board forms on file with the employer pertaining to an employee s claim. A worker injured on the job must select a doctor from the list below. The minimum traditional panel shall consist of at least 6 physicians, including an orthopedic surgeon with no more than two physicians from industrial clinics (see O.C.G.A ). Further, this panel shall include one minority physician, whenever feasible (see Rule 201 for definition of minority physician). The Board may grant exceptions to the required size of the panel where it is demonstrated that more than four physicians are not reasonably accessible. One change to another doctor from the list may be made without permission. Further changes require the permission of the employer or the State Board of Workers Compensation. State Board of Workers Compensation 270 Peachtree St., N.W. Atlanta, GA (404) Or OCCUPATIONAL CLINICS WELLSTAR U.S. HEALTH WORKS MEDICAL GROUP 3805 Cherokee St., Kennesaw (770) Franklin Rd. Ste. 103, Marietta, GA Sandy Plains Rd., Marietta (770) (770) Delk Rd., Marietta (770) N. Cooper Lake Rd., Smyrna (770) The Bluffs Suite 100, Austell GA Cobb Parkway, Acworth (770) (404) ORTHOPAEDICS CHRISTOPHER EDWARDS, MD (Spine Specialist) EZEQUIEL CASSINELLI, MD (Spine Specialist) 1634 White Circle Johnson Ferry Rd Ste Peachtree Dunwoody Marietta, GA Marietta, GA Atlanta, GA (404) Downwood Circle NW Suite 700 Atlanta, GA (404) CENTER FOR ORTHO & SPORTS MEDICINE BRANDON BURRIS, MD (General Orthopaedics) CENTER FOR ORTHO & SPORTS MEDICINE NICOLAS BONNAIG, MD (General Orthopaedics) CRAIG WEIL, MD (Upper Extremity) 300 Tower Rd. Suite Johnson Ferry Rd. Marietta, GA Marietta, GA (770) ext (770) GLENN JONAS, MD (Upper Extremity) PODIATRIST 270 Chastain Rd. NATHAN SCHWARTZ, DPM Kennesaw, GA Ankle & Foot Centers of Georgia (404) Windy Hill Rd. Smyrna, GA (770) The employer/insured providing coverage for this business under the Workers Compensation Law is: COBB COUNTY SCHOOL DISTRICT P.O.BOX 1088, MARIETTA, GA (770) IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS COMPENSATION AT OR OR VISIT Willfully making a false statement for the purpose of obtaining or denying benefits is a crime subject to penalties of up to $10, per violation (O.C.G.A and ). (WC-P1 3/2018)
4
5 Carlisle Medical/RESTAT Making a Difference Workers Compensation Prescription Information M-F 10am-6pm CST Please present this information to any participating pharmacy for prescription processing Employee Name: (Please Print) Social Security Number (used as Member ID) : - - Date of Birth: Date of Injury: Plan/Group Number: W 908 Member Number: Employee s SS # - - (plus the injury date, NO dashes MM/DD/YY) RESTAT Bin Number: Person Code: 000 Our employee has been injured in a work related accident. Please use the information above to process prescriptions for Cobb County School District. If you have questions, please call our office. Thank You. Donna Davidson, Medical Claims Adjuster Office ~ Fax ~
6 COBB COUNTY SCHOOL DISTRICT Workman s Compensation ~ Risk Management Mileage Reimbursement Form Fax # EMPLOYEE NAME: DATE STARTING ADDRESS (use complete address with city/zip) DESTINATION~ ADDRESS (Ie: PT, Dr Appt,etc.-use complete address with city/zip ) MILES Roundtrip One Year Deadline With Regard to Medical Expenses Section 4 of SB 233 also creates O.C.G.A (c)(4), which provides for a one year deadline with regard to medical expenses. It states that, Notwithstanding any other provisions of this subsection, if the employee or the provider of healthcare goods or services fails to submit its charges to the employer or its workers compensation insurer within one year of the date of service of the issuance of such goods or services, then the provider is deemed to have waived its right to collect such charges from the employer, its workers compensation insurer, and the employee.
7
THIS 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) 594-8580 Office Fax
More informationOFFICIAL NOTICE. This business operates under the Georgia Workers' Compensation Law.
CADUCEUS OCCUPATIONAL MEDICINE 1580 BOGGS RD., SUITE 700 770-255-0790 24/7 MEDICAL CARE CHOICE CARE OCCUPATIONA L MEDICINE AND ORTHOPAEDICS 6760 JIMMY CARTER BLVD, # 150 678-892-2000 24/7 MEDICAL CARE
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 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 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 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 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 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 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 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 informationTRINITY CHARTER SCHOOLS EMPLOYEE STATEMENT OF INJURY
EMPLOYEE STATEMENT OF INJURY This form is to be completed in its entirety by the Employee No Later than the End of the Shift Fax this form to Texas Healthcare Foundation (972) 317-0889 Form 1-11/2009 Any
More informationLakeside Foot & Ankle Center Karsten Weber, DPM * Alex Stirling, DPM* Nicole Hancock, DPM
Karsten Weber, DPM * Alex Stirling, DPM* Nicole Hancock, DPM Patient Information Name: Date of Birth: Sex: Street Address: City: State Zip Mailing Address (if different) City: State Zip Phone # Cell Phone
More informationPATIENT INFORMATION FORM
PATIENT INFORMATION FORM Alpharetta Braselton Cumming East Cobb Johns Creek Marietta Sandy Springs Sugar Hill West Paces Woodstock www.napc.md ALL PATIENTS OR RESPONSIBLE PARTIES MUST COMPLETE THIS FORM
More informationCHEROKEE COUNTY BOC Workers Compensation Accident Report Packet
CHEROKEE COUNTY BOC Workers Compensation Accident Report Packet Rev 1/2/18 Cherokee County Board of Commissioners Human Resources Department 1130 Bl uffs Parkway Canton, GA 30114 Phone: 678-493-6019 ~
More informationCherry 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 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 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 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 informationCherry 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 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 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 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 informationEMPLOYEE INSTRUCTIONS FOR CLAIMS REPORTING
EMPLOYEE INSTRUCTIONS FOR CLAIMS REPORTING Please read the entire contents of the packet and follow directions below. 1. Call 1-800-445-6965 to report your work-related claim as soon as possible. 2. Advise
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 informationEmployee s Report of Work-Related Injury University of Maryland, College Park
Employee s Report of Work-Related Injury To be completed immediately after the accident or initial treatment and submitted to your supervisor Employee Name: UID: Male (First) (Last) Female Date of Birth:
More 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 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 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 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 information*5135 Dixie Hwy location has relocated to 6801 Dixie Hwy Ste 134*
*5135 Dixie Hwy location has relocated to 6801 Dixie Hwy Ste 134* Dear Patient, The offices of Tipton & Unroe would like to welcome you to our practice! We are Louisville s premier provider for foot and
More informationEMPLOYEE INSTRUCTIONS FOR CLAIMS REPORTING
EMPLOYEE INSTRUCTIONS FOR CLAIMS REPORTING Please read the entire contents of the packet and follow directions below. 1. Call 1-800-445-6965 to report your work-related claim as soon as possible. 2. Advise
More informationMadison National Life Insurance Company, Inc. P.O. BOX 2865 CLINTON, IA Telephone: Extension 2410 Fax:
EMPLOYEE S STATEMENT OF CLAIM FOR BENEFITS As your disability insurer we are committed to assisting you in a return to health and to productive employment. Please complete the following form as thoroughly
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 informationSurname Given names Date of birth / / Address State Postcode. please advise police station or first aid service to which the accident was reported
Claim form Income replacement This form is to be completed by the life insured. To be completed only on the request of the Zurich claims area. To avoid delays, check that all questions have been answered
More informationChristina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA Phone Fax:
Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA 98005 Phone 425-301-9869 Fax: 866-546-1618 Welcome to my practice. I look forward to meeting with
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 informationCardiology Consultants of Atlanta, P.C N. Decatur Rd. Suite 395, Decatur GA, (404) phone (678) fax
OFFICE POLICIES AND PROCEDURES Thank you for choosing Cardiology Consultants of Atlanta for your cardiovascular care. We realize that you have a choice in medical providers and are pleased that you have
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 informationPatient Demographic Information
Maurice Jové, M.D. Nathan Jové, M.D. Jeff Traub, M.D. Brian Vanderhoof, D.O Farhan Malik, M.D. Patient Demographic Information First Name Last Name M.I. Address City State ZIP Code E-Mail Address Home
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 informationToday s Date (mm/dd/yyyy):
115 Christopher Columbus Drive, Suite 301 Jersey City, New Jersey 07302 201-706-3808 http://www.drsmedicalassociates.com/ WELCOME TO DRS MEDICAL ASSOCIATES LLC. PLEASE COMPLETE THE FORM LEGIBLY AND ENTER
More informationBRICKSTREET INJURY KIT
West Virginia BRICKSTREET INJURY KIT POLICY # COMPANY NAME CONTACT PERSON AND NUMBER JURISDICTION Your Business. Your People. You re Covered. 866.452.7425 brickstreet.com BRICKSTREET INJURY KIT SUPERVISOR
More informationIF THE INSURANCE INFORMATION IS NOT IN YOUR NAME WE MUST HAVE THE FOLLOWING.
A FAMILY TRADITION ROBERTS CHIROPRACTIC CENTER, PA Date of appointment: Name: Last First Middle Name No nicknames please Birth date Address: Please no P. O. Boxes Age: Sex: F M City State Zip Are you Hispanic?
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 information2018 Claim Reporting and Management
2018 Claim Reporting and Management 900 Route Nine North, Suite 503, Woodbridge, NJ 07095 Toll-free Phone: (800) 446-7647 Website: www.gsmjif.com Main Number: (732) 634-8400 Fax: (732) 634-6312 GARDEN
More informationPHARMACY INFORMATION
NAAMAN CLINIC TODAY S DATE: Prefix Mr. Mrs. Miss Ms. Dr. Preferred Name: Patient s Name Address: First Middle Last Street & Apt # City State Zip SS# Birthdate Age: Sex: Female Male Marital Status: Single
More informationPolicy: Financial Assistance Policy for Emory Healthcare
Policy: Financial Assistance Policy for Emory Healthcare OVERVIEW As the leading provider of health care services in the state of Georgia, Emory Healthcare is committed to providing financial assistance
More informationGROUP SHORT-TERM DISABILITY STATEMENT OF EMPLOYEE
GROUP SHORT-TERM DISABILITY STATEMENT OF EMPLOYEE 1. Full Name (last, first, middle initial) 2. Social Security Number 3. Phone Number (include area code) 4. Street Address & Mailing Address 5. City 6.
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 informationEmployer/Doctor Employer s Name Address: Referring Doctor Phone Number Primary Doctor Phone # Patient Information
FINANCE INSURANCE ORTHOPEDIC SPINE AND SPORTS MEDICINE CENTER 2 FOREST AVEPARAMUS, NJ 07652 PATIENT QUESTIONAIRE Patient s Name: Last First (legal): Middle Initial: Address: City: State: Zip: Date of Birth:
More information(1) Ambulatory surgical center (ASC) means any center, service, office facility, or other entity that:
.1 Definitions. Subtitle 09 WORKERS' COMPENSATION COMMISSION 14.09.08 Guide of Medical and Surgical Fees Authority: Labor and Employment Article, 9-309, 9-663 and 9-731, Annotated Code of Maryland Effective
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 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 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 informationEMPLOYER S INJURY ILLNESS REPORT
EMPLOYER S INJURY ILLNESS REPORT 1. Employee Name 2. Branch Office ID 3. Date of Injury 4. Time of Injury 5. Date Reported 6. Social Security # 7. Full Home Address 8. Home Phone Number: 9. Gender Male
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 informationName: DOB: SS: Mailing Address: City: State: Zip: Home #: Cell phone #: Martital Status: Address:
Patient Information: Name: DOB: SS: Mailing Address: City: State: Zip: Home #: Cell phone #: Martital Status: Email Address: Race: Ethnicity: Gender: Primary Language: Preferred Spoken Language: Would
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 informationBUSINESS INSURANCE GROUP P.O.
WELCOME We are glad you insured with Alabama Workers' Compensation Self-Insurance Fund (AlaCOMP) through Business Insurance Group. We are confident you will be happy with your decision. Our goal is to
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 informationCLAIM FORM. DATE OF BIRTH: 3. PATIENT'S NAME & ADDRESS- IF ADDRESS IS NEW, PLEASE CHECK BOX r PHONE: ( )
PRIMERICA LIFE INSURANCE COMPANY as Administered by Senior Health Ins. Co. of Pennsylvania Home Office: Boston, MA P.O. Box 64913 St. Paul, MN 55164 Telephone: 1-877-451-5824 CLAIM FORM The patient or
More informationSubmitting Your Disability Claim
Submitting Your Disability Claim Personalized support every step of the way! Cherokee County Board of Commissioners GL.2017.139 How to file a disability claim Disability coverage is a valuable benefit
More informationINSURED STATEMENT OF CLAIM
INSURED STATEMENT OF CLAIM Last Name First MI Address Apt No. City State Zip Telephone No. - - Home Cell Work E-Mail Address: Birth Date / / Soc. Sec. No. Policy Number Gender: M F Height Weight Spouse
More informationAAU Registered Member Sports Accident Claim Procedure
AAU Registered Member Sports Accident Claim Procedure AAU members may be eligible for medical expense benefits for treatment of covered injuries sustained while participating in AAU Licensed activities.
More informationPARAGON Physical Therapy, PC
WELCOME TO PARAGON Physical Therapy. Who can we thank for referring you? We appreciate you choosing PARAGON Physical Therapy, PC to be your provider of physical therapy services. If you would not mind,
More informationWorkers' Compensation Packet. This packet contains forms that must be used when completing a Workers' Compensation claim.
2016-2017 Workers' Compensation Packet August 31, 2016 This packet contains forms that must be used when completing a Workers' Compensation claim. Please throw away the previous packet. Richmond City Public
More informationBENEFICIARY S STATEMENT Failure to complete all sections may result in a delay in processing of the claim.
Post Office Box 84075 * Columbus, GA. 31993 Phone (800) 433-3036 * Fax (866) 849-2970 groupclaimfiling@aflac.com BENEFICIARY S STATEMENT Failure to complete all sections may result in a delay in processing
More informationIMPORTANT: PLEASE SIGN AND DATE AUTHORIZATION ON THE FINAL PAGE OF THIS FORM
Please mail completed claim form to: Trustmark Insurance, 100 North Parkway, Suite 200, Worcester, MA 01605 Phone: 877-201-9373, Fax: 508-853-2757 IMPORTANT: PLEASE SIGN AND DATE AUTHORIZATION ON THE FINAL
More informationPATIENT INFORMATION DEMOGRAPHICS. First Name Middle Initial Last Name Gender. Mailing address: Apt # City: State: ZIP Code: Home Phone Cell Phone
PATIENT INFORMATION Gary S. Fields, DPM, FACFAS Kenneth M. Danis, DPM, FACFAS DEMOGRAPHICS First Name Middle Initial Last Name Gender SSN Birthdate Age Email M F Mailing address: Apt # City: State: ZIP
More informationYOUR RIGHTS UNDER THE MISSOURI WORKERS COMPENSATION LAW
YOUR RIGHTS UNDER THE MISSOURI WORKERS COMPENSATION LAW What is the Workers Compensation Law? The workers compensation law, found in Chapter 287 of the Revised Statutes of Missouri, controls the rights
More informationRavi Yalamanchili M.D, P.A. Patient Registration / Information Sheet Last Name: M.I. Sex: Female Male First Name: Marital Status:
We do not Accept Checks Ravi Yalamanchili M.D, P.A. 141 Thomas Johnson Drive, Suite 200 Frederick, MD 21702 Phone 301-846-0100 Fax 301-846-0244 Please Print Patient Registration / Information Sheet Last
More informationSPORTING ACCIDENT CLAIM FORM Eastern Football League
Dear Member, SPORTING ACCIDENT CLAIM FORM Eastern Football League Please read this page first before completing the Claim Form Sportscover Australia Pty Ltd Thank you for your Claim Form request. This
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 informationZURICH AMERICAN INSURANCE COMPANY BLANKET ACCIDENT INSURANCE POLICY PROOF OF COVERED LOSS FORM Mail claims to: INSTRUCTIONS
ZURICH AMERICAN INSURANCE COMPANY BLANKET ACCIDENT INSURANCE POLICY PROOF OF COVERED LOSS FORM Mail claims to: Administrative Concepts, Inc. 994 Old Eagle School Road Suite 1005 Wayne, PA 19087-1802 www.visit-aci.com
More informationAccident Reporting Packet
Accident Reporting Packet Employee/ First Name: SSN: Last Name: Position: Date of Hire: When an accident occurs, no matter how minor, please call Corporate Solutions 1-888- 785-4018 immediately and report
More informationSANILAC COUNTY ROAD COMMISSION EMPLOYMENT APPLICATION FOR CDL POSITION 35 N. Flynn Street Sandusky, MI 48471
SANILAC COUNTY ROAD COMMISSION EMPLOYMENT APPLICATION FOR CDL POSITION 35 N. Flynn Street Sandusky, MI 48471 (810) 648-2185 FAX (810) 648-5810 Equal access to programs, services, and employment is available
More informationHM Worksite Advantage Disability Income Claim Form
Instructions Disability Claim 1. Complete Part 1, the Insured Information/Claimant Statement and read and sign the Certification. The Certification will be used to obtain the information needed to process
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 informationMadison County Board Of Education
JOB-RELATED INJURY INSTRUCTIONS In compliance with Board Policy FILE: 5.9.4, Absences Due to Job-Related Injuries, the following instructions must be followed when injuries occur on the job. Please read
More informationShort Term Disability Claim Form
Short Term Disability Claim Form Important notice to employee Please read carefully: You or someone acting on your behalf should complete Section 1 and then have your employer complete Section 2. Have
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 informationSection 4: Authorization for Use and Disclosure of Protected Health Information Between WEA Trust Plans
Instructions This form or other similar written notice of claim must be submitted within 90 days of the onset of your alleged disability. If you have any questions, call WEA Trust at 608.276.4000 or 800.279.4000.
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 informationPatient Information Form
Patient Information Form General Information Today s date / / Patient s name Last name First name Middle initial Address Street City State Zip code # ( ) # ( ) Work # ( ) Preferred telephone contact Work
More information14 Mill Park Court Newark, DE Office: Fax: Time:
FIRST REPORT OF INCIDENT PERSONAL INJURY WC PROJECT DATA PERSONAL DATA Date of Incident: Date of Report: Project Manager: 14 Mill Park Court Time: or PM AM Day of Week Time of Report: or PM Project No.:
More informationGROUP DISABILITY CLAIM APPLICATION
GROUP DISABILITY CLAIM APPLICATION Return original claim forms to: Bay Bridge Administrators, LLC P.O. Box 161690 Austin, TX 78716 Short Term Disability (STD) TEL: (800) 845-7519 FAX: (512) 275-9350 Long
More informationShort Term Disability Claim Form
Life and Disability products underwritten by. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. 63823MUMENLIC Rev. 3/17 1 of 6 1928530 63823MUMENLIC Short Term Disability Claim Packet
More informationMorris Medical Center, P.A.
Thank you for choosing our practice to assist in your healthcare needs. We appreciate the confidence you and your personal physician have placed in us. Please read the following instructions and information
More informationOccupational Accident Claim Filing Instructions
Occupational Accident Claim Filing Instructions In addition to the Occupational Accident Report of Injury claim forms please provide the following information. Failure to submit all of the requested information
More informationFor any other Claim or Risk related questions please see the contact table below. REQUEST / REPORTING
The enclosed information includes workers compensation claim reporting instructions and forms. Please carefully review this information to ensure timely reporting of work related injuries/illnesses and
More informationADDRESS: Street City State/Zip (Please give complete address including Zip Code otherwise claim cannot be processed) OCCUPATION: DEPT:
REPORT OF EMPLOYEE INJURY Answer all questions fully. If not applicable, reply N/A EMPLOYEE INFORMATION NAME: GENDER: Male: Female: ADDRESS: Street City State/Zip (Please give complete address including
More informationFRESNO COUNTY EMPLOYEES RETIREMENT ASSOCIATION. APPLICATION FOR DISABILITY RETIREMENT (Please type or print legibly in ink)
FRESNO COUNTY EMPLOYEES RETIREMENT ASSOCIATION (Please type or print legibly in ink) Board of Retirement 1111 H Street Fresno, California 93721 Gentlemen: PART A PERSONAL INFORMATION I have become permanently
More informationNOTICE OF CLAIM FOR DAMAGES AGAINST THE COUNTY OF PASSAIC
NOTICE OF CLAIM FOR DAMAGES AGAINST THE COUNTY OF PASSAIC -- -- -- For 1. and to: CLAIMANT: PASSAIC COUNTY LEGAL DEPARTMENT PASSAIC COUNTY ADMINISTRATION BUILDING 401 GRAND STREET PATERSON, NEW JERSEY
More informationRULES OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT DIVISION OF WORKERS COMPENSATION
RULES OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT DIVISION OF WORKERS COMPENSATION CHAPTER 0800-02-06 GENERAL RULES OF THE WORKERS COMPENSATION PROGRAM TABLE OF CONTENTS 0800-02-06-.01 Definitions
More informationShort Term Disability Claim Form
Short Term Disability Claim Form Important notice to employee Please read carefully: You or someone acting on your behalf should complete Section 1 and then have your employer complete Section 2. Have
More informationPersonal Injury Claim Notification pursuant to the Civil Law (Wrongs) Amendment Regulation 2004
Personal Injury Claim tification pursuant to the Civil Law (Wrongs) Amendment Regulation 2004 Complete the form in BLOCK LETTERS Provide details on separate sheets if required To Respondent Address Name
More informationPHYSICAL THERAPY WELCOME PACKET
PHYSICAL THERAPY WELCOME PACKET Thank you for choosing Michael Johnson Physical Therapy. This welcome packet contains six forms. Please see instructions below and complete the forms accordingly. 1. New
More informationof all prescription and non-prescription medications or supplements
Diplomate, American Board of Podiatric Surgery Fellow, American Board of Foot and Ankle Surgeons 1201 Medical Plaza Court Granbury, Texas 76048 817-578-8555 brazosfootandankle.com Dear Patient: Thank you
More informationShort Term Disability Claim Form
Short Term Disability Claim Form Important notice to employee Please read carefully: You or someone acting on your behalf should complete Section 1 and then have your employer complete Section 2. Have
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 information