This checklist worker's compensation claims template has 6 pages and is a MS Word file type listed under our human resources documents.
Sample of our checklist worker's compensation claims template:
CHECKLIST Handling Workers' Compensation Claims The initial period is critical in handling workers' compensation claims. So you must be sure to: Immediately Administer first aid Accompany injured worker to a selected medical provider Report incident within company Notify family Assign responsible person to follow claim First day Report to claim handler outside company (insurance company or third-party administrator) Determine, on a preliminary basis, whether the injury is covered by workers' compensation Counsel employee and/or family on claims procedures, available benefits, company's continuing interest in employee's welfare, etc. Follow up with the employee or family First week Coordinate payment of initial benefits Talk to treating physician to learn diagnosis and treatment plan Evaluate whether medical rehabilitation is necessary or appropriate Develop return-to-work plan Contact the injured employee and/or the family and forward mail First month Use a "wellness" approach (cards, phone calls, visits) to continue to reinforce company's concern Consider medical examination by independent physician, if warranted Reevaluate treatment plan based on new medical information Update return-to-work plan and contact the injured employee and/or the family Ongoing Continually reevaluate treatment plan Refer for pain management evaluation of chronic pain, if appropriate Maintain contact with the injured employee and/or the family Checklist for collecting information FOR a claim Whether it's the businesses owner, or someone assigned by the business owner to keep track of the claim, here's some advice for the types of information the person overseeing the claim should be gathering: About the employee Name, nicknames, maiden name, previous names Address-current and previous (length of time living at both addresses) Phone number, pager number, cellular number Social security and driver's license numbers Sex Date of birth Marital status Dependents and immediate family contact Non-relative contact Date of hire (state hired, if applicable) Job classification, if applicable (insurance class or company classification) Vehicle (type, year, license number) Interests-hobbies Length of time as a state resident About the injury Time and date of injury Date of death (if applicable) State of injury Nature of injury (sprain, fracture, etc.) Body part(s) affected; any previous injury to the affected body part(s) Source of injury (machines, hand tools, buildings, etc.) Type of injury (fall, struck by object or vehicle, overexertion, repetitive motion trauma) Witnesses Work process involved (lifting, carrying, etc.) To whom was the injury reported Who filled out the first report of injury report Plant or location Job Time and date the injury was reported Shift, if applicable About the claim Date employer first notified Who was notified, by whom? Date employer was notified of workers' compensation claim Date insurance company or service company notified Date state agency notified State case number Average weekly wage Benefit rate Health care providers and costs Other benefits lost (Did the employer stop paying vacation, health benefits, etc.?) Other benefits received Date disability started Date of first payment Projected return-to-work date Date case closed Date of maximum medical improvement Impairment rating Lost days Total benefits paid Vocational rehabilitation activity Subrogation (Is some third party responsible?) Second injury fund potential Oral statement from injured worker Conduct the interview in a non-adversarial setting Demonstrate concern and empathy Allow the worker to talk Do not rush the worker Reenact the accident Check for photos and/or video of the accident Written statement from injured worker Note the location where the statement is taken Let the employee write the statement, if possible Statement is taken ASAP after the injury Describe the worker' pre-injury and post injury actions Request that the worker and any witnesses sign the statement Make sure the employee initials any changes Give copy of statement to employee list the date and time of the statement Oral statement from witness(es) Note witness' location at the time of injury Record witness' relationship to the injured worker Interview witnesses individually Do not rush the witness Make sure the statement is unrehearsed Written statement from witness(es) Make sure the witness writes the statement in ink Record the stated ASAP after the injury Make sure the witness records his/her actions before, during and after the time of injury Request that the witness sign the statement and initial any changes Record the date and time of the statement Give a copy of the statement to the witness If litigation occurs Defense attorney, law firm Claimant attorney, law firm Identify judge Costs of litigation (spending more than paying?) History of dispute Settlement Warning Signals of Workers' Compensation Fraud You may not discriminate against a worker who has filed previous workers' compensation claims
