Employee Workers' Compensation Poster

Employee Workers' Compensation Poster

This notice summarizes employee rights and employer responsibilities under applicable workers' compensation law. Employers must promptly report workplace injuries and provide timely notice of benefits and claim procedures. This poster shall be displayed where employee notices are normally posted.

Employer Information (to be completed by employer)

Workers' Compensation Insurance Information

Indicate the employer's workers' compensation status and provide insurer contact information. If self-insured, provide claims contact.

How to Report an Injury

Employees must report any work-related injury or occupational illness to the employer as soon as possible. Report to the named supervisor or company representative below. Prompt reporting is required to preserve claim rights; failure to report may affect benefits as provided by law.

Sample Injury Report (for employee use)

This sample form may be used to provide immediate notice to the employer. Provide as much detail as possible. Submit a copy to the employer and to the insurer or claims administrator as instructed above.

Date of Injury:    Time of Injury:    Location of Injury:

Medical Treatment and Benefits (Summary)

Employees injured on the job are entitled to reasonable and necessary medical treatment related to the work injury, as required by applicable law. Compensation for lost wages and other statutory benefits are determined under workers' compensation statutes and administered by the insurer or claims administrator. Eligibility and benefit levels are governed by law and by claim adjudication; this notice summarizes key obligations but does not replace statutory provisions.

If required by law, temporary disability benefits may commence following any statutory waiting period for wage replacement. Permanent impairment benefits, vocational rehabilitation, and death benefits may be available where applicable. All benefits are subject to claim approval and medical documentation.

Employee Rights and Protections

It is unlawful for an employer to discharge, discipline, retaliate against, or otherwise discriminate against an employee for reporting a workplace injury, filing a workers' compensation claim, or cooperating in an investigation or proceeding concerning a claim. Employees may be entitled to remedies under applicable law if retaliation occurs.

Employees have the right to obtain an independent medical opinion and to request information regarding the status of their claim. Employees should keep records of all medical visits, correspondence, and time lost from work related to the injury.

Filing a Claim and Appeal Rights

To initiate a claim, provide notice to the employer and, when required, complete and submit any claim form required by the insurer or claims administrator. If a claim is denied in whole or in part, employees have the right to appeal under procedures established by statute and may request a hearing before the appropriate adjudicative body.

Employer Posting & Acknowledgment

The employer certifies that this workers' compensation poster has been posted in a conspicuous location accessible to employees and that the information above is accurate to the best of the employer's knowledge. A copy of this completed poster shall be provided to employees upon request.

Date Posted:    Location Posted:

Certification: I certify under penalty of perjury that the information provided on this poster is true and correct and that this poster is displayed in accordance with applicable workers' compensation posting requirements.

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