Employee Safety: Safety – Workers’ Compensation Forms

When an employee experiences a workplace injury or illness, workers’ compensation insurance covers related medical care, part of lost wages and permanent disability. Employees should report all work-related injuries to their supervisors immediately no matter the severity. Human Resource Management’s Risk and Safety Management.

The employee’s supervisor completes a thorough investigation of the incident using the workers’ compensation checklist below and submits it to OMES-State Risk Management and HRM-Risk and Safety Management.

Worker’s Compensation Email/Fax Cover Sheet

Worker’s Compensation Checklist

Workers’ Compensation Incident Investigation Report

Gallagher Bassett Authorization for Release of Information

Authorization for Initial Treatment

Gallagher  Bassett PPO Network Providers

Workers’ Compensation First Script Prescription Form

First Script Participating Pharmacies

Return to Work Form

Leave Option Election

For questions regarding Worker’s Compensation forms contact Metish Farrow.

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