Departmental Accident Report Form for Workers’ Compensation Benefits Sample Clauses

Departmental Accident Report Form for Workers’ Compensation Benefits. REMEMBER… In addition to filing the necessary forms, you must provide your supervisor with medical documentation (a doctor’s note) to cover your absence as well as keep him/her properly updated with respect to your anticipated return to work date. You do not fill out a disability claim form (DB-450) unless you receive a “C-7” (Notice of Controversion) from the insurance carrier or the Worker's Compensation Board. WHO TO CALL TO FOLLOW UP ON YOUR CLAIM OR IF YOU NEED INFORMATION: Xxxxxxxxx Xxxxxxx Tel. 000-000-0000 OR Disability Benefits Office Tel. 000-000-0000 Sick Leave, Disability & Worker's Compensation (TWU, Local 241) Sick Leave Disability Workers’ Compensation HIRED ON OR AFTER 3/1/96 After 4 months-1 year -- 1 day per month, retroactive to date of hire, up to a maximum of 12 days per year After 1 year -- 12 days per year BANK: 60 days maximum The first five (5) days of sick leave charged to the employee’s annual allotment at the rate of a full day for each day of absence. Thereafter, for continuing absences of more than five (5) consecutive days, each full day of sick leave is charged to the employee’s sick bank for each day of absence until the sick leave bank is used up. Once the sick bank is exhausted, an employee must use their remaining annual allotment of sick leave. Employee may chose to: 1) receive N.Y. State Workers' Compensation benefits to the extent he/she is entitled, or 2) use 10 days sick leave, if available and thereafter, use sick leave, if any, to maintain the full difference between the Workers' Compensation benefits and a full day's pay for each day of absence, according to the following schedule: Less than 1 year -- 1 work week 1-3 years -- 2 work weeks 3-5 years -- 3 work weeks 5-7 years -- 4 work weeks 7-9 years -- 5 work weeks 9+ years -- 6 work weeks NOTE: An employee will not receive N. Y. State Disability benefits while he/she is receiving sick leave pay. If the employee's sick leave is exhausted during the period covered by N. Y. State Disability (26 weeks during a period of 52 consecutive weeks), the employee will receive N.Y. State Disability benefits, to the extent to which he/she is entitled, for the balance of the 26-week period. NOTE: Upon exhausting his/her sick leave or having supplemented his/her pay to the extent provided by the above schedule (whichever comes first), the employee will receive the statutory Workers' Compensation benefits to the extent to which he/she is entitled. Security Officers hired after 3...
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