What
to File?
To file a claim for Worker's Compensation for an injured
employee following are the steps to be taken and the necessary forms:
Instructions: Print
a blank form and fill it in manually, or download the file to
your desktop and complete the form as a Word document. Please
forward all completed forms to the Human Resources Department.
Step 1: Employer's
First Report of Injury or Fatality (Form 101)
This form is
to be completed in its entirety by your employer and
must be filed within seven (7) calendar days, not including Sunday
and
legal
holidays,
or receipt of notice of any injury alleged
to have risen out of and
in the
course
of
employment
which incapacitates
an employee
whether it involves medical care
only or from earning full wages
for a period of five (5) or more calendar days.
Step 2: Supervisor Accident
Investigation Report [Word.doc]
Supervisor
Accident Investigation Report [PDF]
This form is to be completed by your supervisor upon
completion of the accident investigation and within seven (7) calendar
days of the accident.
Step 3: Release of Information
This form is to be completed and
signed by the employee to
release medical information to MHC or representative on
information relating to the injury.
Step 4: Initial/Supplemental Medical Treatment Form
This form is to be completed by your medical provider when
medical treatment is provided.
|
