BB&T Accident, Injury, Illness and Workers’ Compensation Report
All Accidents/Injuries/Illnesses – MUST be reported within 48 hours with or without Medical Treatment
I. General Information:
Employee Name: / Employee Identification Number:Social Security # (required for insurance) / - / - / Date of Hire (mm/dd/yyyy): / / / /
Job Title: / How long in this position? / Years / Months
Age: / Full-Time: / Part-Time: / Gender: / Male / Female
Home Address: / Home Phone # : (including area code) / - / -
Home City: / Home State: / Zip
Work Address: / Work Phone # (including area code) / - / -
Work City: / Work State: / Zip
Cost Center Name & Number: / Banking Region:
II. Description of Accident/Injury/Illness:
The property where the Accident/Injury occurred is: / Bank Owned / Leased / Off SiteIf the property is leased, provide Leasing Company Name:
Leasing Company Address: / Phone # (including area code) / - / -
City: / State: / Zip
Date of Accident/Injury/Illness (mm/dd/yyyy): / / / / / Time of Accident/Injury/Illness: / AM
PM
Describe Accident/Injury/Illness: (Please be specific and provide as many details as possible.)
If this is an automobile accident, provide the address or intersection where the accident occurred:
Address/Intersection: / City/State: / Zip
Did employee seek medical attention? / Yes: / No: / (If YES, complete, section IV, A or B. If NO, complete section IV, C)
Facility where medical treatment was received: / Date of Treatment: / / / /
Medical Facility Location: / Telephone Number: / - / -
Treatment : (if known) / Days missed from work due to accident/injury/illness:
If employee missed time from work, has the employee returned to work? Yes No
ALL STATES: Please contact the Human Systems Service Center at 800.716.2455, option 1 or asap to advise if employee has missed time away from work due to the accident, injury or illness.
III. Corrective Action Taken (Please provide as many details as possible)What action, if any, has been taken to eliminate the hazard? Has the hazard been reported to Support Services, Facilities? / Yes / No
IV. Reporting Process:
· If medical attention is required, immediately call Hartford’s Teleclaim Service Center at 800-327-3636 to report a Workers Compensation Claim.
· Provide the following required information when reporting the claim:
BB&T Account #: 78600, Policy #: 22WNMS9256 (for Wisconsin, use Policy # 22WBRM59253)
Employee’s Cost Center Number: / (Also called LARS Code/Reference Code)
· You will verbally receive a claim number. Document claim number here:
Forward copies of ALL supporting documentation (doctor’s notes, leave of absence paperwork, etc.) relating to the employee’s claim to your Regional Employee Relations office.
For BB&T records and processing, please forward copies of the completed report to:
BB&T Benefits Administration
Attn: Workers’ Compensation
PO Box 1215 AND
Winston-Salem, NC 27102
Mail Code: 001-16-10-10 / BB&T Human Systems
Attn: Corporate Safety & Health
223 West Nash Street, 6th Floor East
Wilson, NC 27893
Mail Code: 100-01-06-81
B. REQUIRING Medical Attention (West Virginia ONLY)
· If medical attention is required, immediately call BrickStreet’s Teleclaim Service Center at 866-452-7425, select Policy Holder, Option #1 to report a Workers Compensation Claim.
· Provide the following required information when reporting the claim:
BB&T Policy #: WC10018115
Federal Employer Identification Number (FEIN#): 561074313
· You will verbally receive a claim number. Document claim number here:
Forward copies of ALL supporting documentation (doctor’s notes, Leave of Absence paperwork, etc.) relating to the employee’s claim to your Regional Employee Relations office.
For BB&T records and processing, please forward copies of the completed report to:
BB&T Benefits Administration
Attn: Workers’ Compensation
PO Box 1215 AND
Winston-Salem, NC 27102
Mail Code: 001-16-10-10 / BB&T Human Systems
Attn: Corporate Safety & Health
223 West Nash Street, 6th Floor East
Wilson, NC 27893
Mail Code: 100-01-06-81
C. NOT REQUIRING Medical Attention (All States)
For BB&T records and processing, please forward copies of the completed report to:
BB&T Benefits Administration
Attn: Workers’ Compensation
PO Box 1215 AND
Winston-Salem, NC 27102
Mail Code: 001-16-10-10 / BB&T Human Systems
Attn: Corporate Safety & Health
223 West Nash Street, 6th Floor East
Wilson, NC 27893
Mail Code: 100-01-06-81
V. Confirmation:
Report Completed by: / Date: / / / /Employee’s Manager: / Phone: / - / -
Manager’s Signature: / Date: / / / /
Page 1 of 2 CONFIDENTIAL (06/11)