1) Notice -- In most cases you must tell your employer about the accident within 15 days, using the Notice of Accident Form.

2) You have the right to information and assistance from an information specialist known as an Ombudsman at the Workers’ Compensation Administration.

3) Claims information -- Contact your employer’s Claims Representative.

Employer’s Insurer / Claims Representative:

Name:

Phone #:

Address:

Note: Employer must fill in this insurer / claims representative information.

YOUR RIGHTS
If you are injured in a work-related accident:
Your employer / insurer must pay all reasonable and necessary medical costs.

You may or may not have the right to choose your health care provider. If your employer / insurer has not given you written instructions about who chooses first, call an ombudsman. In an emergency, get emergency medical care first.

If you are off work for more than 7 days, your employer / insurer must pay wage benefits to partially offset your lost wages.

If you suffer “permanent impairment,” you may have the right to receive partial wage benefits for a longer period of time.

USE A NOTICE OF ACCIDENT FORM TO REPORT YOUR ACCIDENT TO YOUR SUPERVISOR
EMPLOYER: You are required by law to post this poster where your employees can read it and to post. Notice of Accident forms with it. This poster without Notice of Accident forms does not comply with law. You have other rights and duties under the law.