Workers Compensation Claim Check List

_____Immediately notify and discuss your on-the-job accident/illness with your supervisor.

_____Within 24 hours, complete the online Employee Accident Report. Log in using your PPS or Web Clock ID and password.

Link to form:

_____Complete the online Employee Accident Report form, indicating that you will not be seeking medical treatment.

_____Should you change your mind and wish to see a doctor after your report has already been submitted, call (503) 916-3105 or (503) 916-3703. A PPS Risk Management staff member will locate your accident report and assist you in completing additional paperwork.

_____Complete the online Employee Accident Report form. Handwritten/paper forms no longer provide all information needed to report a WC claim.

_____Print form 801, “Report of Job Injury or Illness.” Print and sign your name on the “worker signature” line, and enter the current date. If you did not print the 801 form upon submitting your report, a copy will be emailed to you at your PPS email address.

** Your signature is required if you are filing a claim for workers’ compensation benefits.

_____Scan & email the signed form 801 to , send via PONY or fax to PPS Risk Mgmt. at (503) 916-3233.

_____Tell the medical provider you are being seen for an on-the-job accident/illness.

_____The attending physician will have you complete form 827, “Worker’s and Health Care Provider’s Report for Workers’ Compensation Claims”. ** Your signature is required if you are filing a claim for workers’ compensation benefits.

_____At each doctor’s appointment, request a work status note to outline your ability to work regular duty, modified duty or no work. Provide the work status note to your supervisor and send a copy to PPS Risk Management via e-mail to or fax to (503) 916-3233.

_____Each time you receive updated information on your work status, notify your supervisor and provide a copy to PPS Risk Management.

_____When you miss time from work, call (503) 916-6970 and leave a voice message reporting the number of hours/days you’ve missed.

_____If not released to regular work, each Monday continue to call (503) 916-6970, leave a voice message to report your work status for the week.

** Examples include:

• “This is (say your name) on (say today’s date). I was injured (say the date) and I missed work (say the time missed).”
• “This is (say your name) on (say today’s date) and my doctor says I’m not able to work the week of (say the dates).”
• “This is (say your name) on (say today’s date) and I’m not working, but my doctor will let me return to light duty work”.
• “This is (say your name) on (say today’s date). I returned to light duty working my regular hours on (say the date).”
• “This is (say your name) on (say today’s date). I returned to light duty on (say the date) working (# of hours per day).”
  Note: If you work reduced hours on light duty, continue calling in on Monday until you return to regular hours.
• “This is (say your name) on (say today’s date) and I returned to regular work on (say the date).”

_____If light duty task assignments are available, you will be contacted by your supervisor, administrator or PPS Risk Management for details.

_____When released for regular work, promptly give the work status note to your supervisor/administrator and a copy to PPS Risk Management.

WORKERS’ COMPENSATION CLAIM & CORRESPONDENCE

_____PPS Risk Management will send your claim documents to our Third-Party Administrator (TPA) for handling. You will be mailed correspondence, via the TPA, containing your claim number and adjuster contact information. You will periodically receive other correspondence from the TPA. Oregon workers’ compensation laws and rules require that certain correspondence be sent by certified and regular mail. It is important that you read all letters and notices and respond timely to requests for information, to prevent a disruption of benefits that may be due to you.

For help contact: Daedra Buntin (503) 916-3105 or Kristen Weiler (503) 916-3703 – mailto: Revised 11/3/14