Employee WC Requirements

EMPLOYEE WC REQUIREMENTS

This form documents mandatory workers' compensation (WC) requirements, employee obligations related to workplace injuries and occupational illness, and the records and authorizations necessary for processing WC claims. Completion and signature acknowledge receipt, understanding, and agreement to comply with the policies and procedures set forth herein.

Personal Information

Employee Name:

Position Information

Employment Start Date:     Salary/Wage:

Workers' Compensation Requirements and Procedures

1. Duty to Report: Employee must report any work-related injury, illness, or exposure to a supervisor immediately and no later than 24 hours after the incident, or as soon as practicable. Failure to report promptly may affect eligibility for benefits. Reported to: Phone:

2. Required Forms and Evidence: To initiate a WC claim the employee must complete an incident report and provide any available witness statements, time records, and initial medical documentation. Required documents include (check all that apply):

3. Medical Treatment: Employee may receive emergency treatment immediately. Non-emergency treatment must comply with employer policy and the WC administrator's medical network if such a network is in effect. Employee authorization for release of medical records related to this incident: I authorize release of relevant medical records to the employer, insurer, and claims administrator.

4. Drug and Alcohol Testing: An employer may require drug and alcohol testing when required by policy or applicable law following a work-related incident. Refusal to submit to testing as required may be grounds for discipline and may affect WC benefits.

5. Fraud Warning: Fraudulent claims, material misrepresentations, or intentional failure to disclose facts relevant to a WC claim are prohibited and may result in denial of benefits, disciplinary action up to termination, and potential civil or criminal liability.

Return-to-Work and Fitness-for-Duty

The employer maintains a return-to-work program that may include transitional or modified duty. Any return to work following medical treatment requires written medical authorization specifying work status, restrictions, and duration. Employee must provide written notes:

Authorization and Release

By signing this form, the employee authorizes the employer, its insurer, and claims administrators to obtain and review medical records and provider information limited to the treatment and condition arising from the reported work-related incident. The employee understands that medical information obtained under this authorization will be used to evaluate WC benefits and return-to-work decisions.

Employee consent to contact prior employers for the purpose of verifying work history as it pertains to the injury, if necessary: I authorize contact.

Required Employment History

Provide at least two prior employers to assist in investigation and verification of work history relevant to WC claims.

Title:    Dates Employed: to

Title:    Dates Employed: to

Education

Graduation Date:

References (Professional)

Reference 1 Name:    Phone:

Reference 2 Name:    Phone:

Reference 3 Name:    Phone:

Legal Disclosures

At-Will Employment: Nothing in this form alters the at-will nature of employment unless expressly set forth in a separate written agreement signed by an authorized representative of the employer. Either the employee or the employer may terminate the employment relationship at any time, with or without cause or notice, subject to applicable law.

Equal Opportunity: The employer does not discriminate in employment or the provision of WC benefits on the basis of protected characteristics. All claims and investigations will be handled in accordance with applicable policies and law.

Applicant / Employee Certification and Authorization

I certify that all information provided on this form is true and complete to the best of my knowledge. I understand that knowingly providing false information in connection with a workers' compensation claim or this form may result in disciplinary action, including termination, and may subject me to civil or criminal penalties under applicable law.

I authorize the employer, its agents, and claims administrators to obtain records, including medical records and employment records, necessary to evaluate any work-related injury or claim. I further authorize my health care providers to release information related to treatment of such injury to the employer, insurer, and designated claims administrators.

I have read, understand, and will comply with the Workers' Compensation requirements and reporting procedures set forth above.

Additional Notes

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