Injury Management and Worker's Compensation

Practice 000.653.1201

Date 01May2009

Attachment 05 Page 1 of 1

INJURY MANAGEMENT AND WORKER’S COMPENSATION

WORKER’S COMPENSATION CLAIM REPORTING

If an employee is injured on the job, call the NationalTelereportingCenter to report a worker’s compensation claim.
Prepare to answer the following questions.
EMPLOYER INFORMATION: / INJURY-RELATED INFORMATION:
Employer (insured) Name / Injured on Employer’s Premises? (Y/N)
Reported By / Injured on Regular Job? (Y/N)
Title / Is Employee Paid in Full for Injury Date? (Y/N)
Phone Number / If Death, Date
State in Which Benefits Will Be Filed / Employer Notified Date/Time
LocationState (if different) / Last Work Date
Location Code / Disability Start Date
Date of Injury / Returned to Work? (Y/N)
Time of Injury / Return to Work Date
Fax Number (optional)
Claim Type (incident, medical only, lost time) / WITNESS INFORMATION:
Mailing Address / Name (first, middle initial, last)
Loss Address (zip code first) / Address (zip code first)
Phone Number
EMPLOYEE INFORMATION:
Social Security Number / DOCTOR INFORMATION (if applicable):
Name (first, middle initial, last) / Name
Sex / Address (zip code first)
Marital Status / Phone Number
Date of Birth
Number of Dependents / HOSPITAL INFORMATION (if applicable):
Race / Name
Home Address (zip code first) / Address (zip code first)
County / Phone Number
Phone Number
INJURY INFORMATION:
EMPLOYMENT INFORMATION: / Safety Equipment Provided? (Y/N)
Occupation / Used? (Y/N)
Department / Initial Treatment (none, minor, ER)
Name of Supervisor / Department Where Injured
Hire Date / Description of Injury
In What State was the Employee Hired? / What was the Employee Doing When Injured?
Employment Status (full/part-time, temporary, seasonal)
Employee Type (owner, partner, corporate officer, contractor) / Light Duty Available? (Y/N)
Salary (per hour, month, or year) / Employer Disagree with Claim (Y/N)
Payroll Schedule (weekly, biweekly, monthly, semi-monthly) / Reason (if applicable)
No. of Hours Worked Per Day
No. of Hours Worked Per Week
Shift Start and End Times

Health, Safety, and Environmental