Common use of Completed Workers’ Compensation Employee Status Report Clause in Contracts

Completed Workers’ Compensation Employee Status Report. The Employer’s First Report of Injury Form This must be forwarded to the Risk Management Department within four calendar days of the occurrence. Note: The injured employee should not complete the Employer’s First Report of Injury, but should assist in completion of the form. • Advise the injured worker that written notice must be delivered to the Risk Management Department within four working days of the accident. • Investigate the claim and complete a Supervisor’s Workers’ Compensation Claim Follow-up Report and forward to the Risk Management Department. If the supervisor feels the claim is not valid, the Risk Management Department should be notified of the fact and the supervisor will submit a written statement verifying why he/she feels the claim should not be honored. • Note: All fatalities and any accident involving three (3) or more employees must be reported immediately by telephone to the Risk Management Office at (000) 000-0000. PERFORMED ACTION: BY: The supervisor will work closely with the Risk Management Department on the following:

Completed Workers’ Compensation Employee Status Report. The Employer’s First Report of Injury Form This must be forwarded to the Risk Management Department within four calendar days of the occurrence. Note: The injured employee should not complete the Employer’s First Report of Injury, but should assist in completion of the form. • Advise the injured worker that written notice must be delivered to the Risk Management Department within four working days of the accident. • Investigate the claim and complete a Supervisor’s Workers’ Compensation Claim Follow-up Report and forward to the Risk Management Department. If the supervisor feels the claim is not valid, the Risk Management Department should be notified of the fact and the supervisor will submit a written statement verifying why he/she feels the claim should not be honored. • Note: All fatalities and any accident involving three (3) or more employees must be reported immediately by telephone to the Risk Management Office at (000) 000-0000. PERFORMED ACTION: BY: The supervisor will work closely with the Risk Management Department on the following:

Completed Workers’ Compensation Employee Status Report. The Employer’s First Report of Injury Form This must be forwarded to the Risk Management Department within four calendar days of the occurrence. Note: The injured employee should not complete the Employer’s First Report of Injury, but should assist in completion of the form. • Advise the injured worker that written notice must be delivered to deliveredto the Risk Management Department within four working days of the accident. • Investigate the claim and complete a Supervisor’s Workers’ Compensation Claim Follow-up Report and forward to the Risk Management Department. If the supervisor feels the claim is not valid, the Risk Management Department should be notified of the fact and the supervisor will submit a written statement verifying why he/she feels the claim should not be honored. • Note: All fatalities and any accident involving three (3) or more employees must be reported immediately by telephone to the Risk Management Office at (000) 000-0000Office. PERFORMED ACTION: BY: The supervisor will work closely with the Risk Management Department on the following:

Completed Workers’ Compensation Employee Status Report. The Employer’s First Report of Injury Form This must be forwarded to the Risk Management Department within four calendar days of the occurrence. Note: The injured employee should not complete the Employer’s First Report of Injury, but should assist in completion of the form. • Advise the injured worker that written notice must be delivered to deliveredto the Risk Management Department within four working days of the accident. • Investigate the claim and complete a Supervisor’s Workers’ Compensation Claim Follow-up Report and forward to the Risk Management Department. If the supervisor feels the claim is not valid, the Risk Management Department should be notified of the fact and the supervisor will submit a written statement verifying why he/she feels the claim should not be honored. • Note: All fatalities and any accident involving three (3) or more employees must be reported immediately by telephone to the Risk Management Office at (000) 000-0000Office. PERFORMED ACTION: BY: The supervisor will work closely with the Risk Management Department on the following:

Completed Workers’ Compensation Employee Status Report. The Employer’s First Report of Injury Form This must be forwarded to the Risk Management Department within four calendar days of the occurrence. Note: The injured employee should not complete the Employer’s First Report of Injury, but should assist in completion of the form. • Advise the injured worker that written notice must be delivered to deliveredto the Risk Management Department within four working days of the accident. • Investigate the claim and complete a Supervisor’s Workers’ Compensation Claim Follow-up Report and forward to the Risk Management Department. If the supervisor feels the claim is not valid, the Risk Management Department should be notified of the fact and the supervisor will submit a written statement verifying why he/she feels the claim should not be honored. •  Note: All fatalities and any accident involving three (3) or more employees must be reported immediately by telephone to the Risk Management Office at (000) 000-0000. PERFORMED ACTION: BY: The supervisor will work closely with the Risk Management Department on the following:

Completed Workers’ Compensation Employee Status Report. The Employer’s First Report of Injury Form This must be forwarded to the Risk Management Department within four calendar days of the occurrence. Note: The injured employee should not complete the Employer’s First Report of Injury, but should assist in completion of the form. • Advise the injured worker that written notice must be delivered to deliveredto the Risk Management Department within four working days of the accident. • Investigate the claim and complete a Supervisor’s Workers’ Compensation Claim Follow-up Report and forward to the Risk Management Department. If the supervisor feels the claim is not valid, the Risk Management Department should be notified of the fact and the supervisor will submit a written statement verifying why he/she feels the claim should not be honored. •  Note: All fatalities and any accident involving three (3) or more employees must be reported immediately by telephone to the Risk Management Office at (000) 000-0000Office. PERFORMED ACTION: BY: The supervisor will work closely with the Risk Management Department on the following: