Attachment I

CLAIMS PROCEDURE CHECKLIST 

Injured employee:

1. Notify supervisor immediately when an incident, injury or exposure to an occupational disease occurs in the course and scope of your job.
2. Notify supervisor or workers’ compensation specialist (claims coordinator) at once if medical services are needed due to a work-related injury or illness. Do not pay for any medical services.
3. If lost time from work occurs, the employee must inform their supervisor that they are off work due to a work-related injury. The employee is required to meet with the claims coordinator to complete an election form as soon as lost time begins. Do not return to work before clearing with the claims coordinator. A medical release will be required.

Supervisor:

1. Complete a Supervisor’s Report of Incident, Injury or Illness. 
2. If applicable, have witness complete a Witness Statement. Send the original Witness Statement to claims coordinator within two work days.
3. Immediately notify the claims coordinator if the employee will need (or has received) medical treatment.
4. Fax or provide a copy of the Supervisor’s Report to the claims coordinator within 24 hours. Sign and send the original report to the department’s additional duty safety officer (ADSO) for review and signature.
5. Do not allow the employee to return to work before clearing with the claims coordinator. A medical release will be required.  

Additional Duty Safety Officer (ADSO): 

1. Complete the review portion of the supervisor’s report and forward to the department head or account manager.
2. Sign and date the report, then forward original report to the department head or account manager.

Department Head or Account Manager: 

1. Notify workers’ compensation specialist (claims coordinator) immediately in case of a serious injury, an injury or illness resulting in death, or if more than one employee is injured.
2. Review Supervisor’s Report, sign, and return the original to the claims coordinator within seven calendar days of processing the Supervisor’s Report. Maintain a copy of the report in the department files. Provide a copy to the Environmental Health, Safety & Risk Management Office.