Employee Workers Compensation Packet

EMPLOYEE WORKERS COMPENSATION PACKET

Employee Name:   Employee ID:

Personal Information

Position Information

Employment History (Most Recent First)

Education

References

Incident Report

Date of Incident:   Time of Incident:

Witnesses

Medical Treatment

Did you seek medical attention?   Yes No

Authorization to Release Medical Information

I authorize any physician, physician assistant, nurse practitioner, hospital, clinic, or other medical provider who has provided treatment to me to release to my employer, the employer's insurance carrier, and their representatives all medical information necessary to process this workers' compensation claim, including but not limited to medical histories, examination results, diagnoses, treatment records, test results and billing information. This authorization is limited to the medical information that is reasonably related to the injury or illness reported in this packet.

I understand that this authorization is subject to applicable law, that protected health information may be redisclosed by the recipient and may no longer be protected by federal privacy regulations, and that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it.

Notice, Acknowledgements and Certifications

I certify under penalty of law that the information contained in this packet is true, complete, and correct to the best of my knowledge. I understand that making a false statement or knowingly submitting false information in support of a workers' compensation claim may subject me to disciplinary action up to and including termination, criminal prosecution, and/or civil liability under applicable law.

I agree to cooperate fully with my employer and the employer's insurance carrier in the investigation and processing of this claim, including attending medical examinations and providing requested records or releases. I understand that failure to cooperate may affect my entitlement to benefits.

Authorization to Contact Previous Employers and Conduct Background Checks

I authorize the employer to contact my prior employers and listed references to verify employment history, duties, and reasons for separation. I also authorize the employer or its authorized agent to obtain background checks and other investigative reports where permitted by law for purposes related to employment and claim handling.

Equal Opportunity and At-Will Employment

The employer is an equal opportunity employer. Employment relationship details, including workers' compensation benefits, do not alter the at-will nature of employment unless otherwise provided in a written agreement signed by an authorized company representative. Nothing in this packet creates a contract of employment or modifies any existing at-will employment relationship.

Employer Use Only

Applicant Certification

I certify that the foregoing information is accurate and complete. I understand that submission of this packet initiates the employer's investigation and the claims process. I agree to provide additional information as requested and to cooperate with medical and administrative processes related to this claim.

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