HomeMy WebLinkAboutWorkers Comp Injury Report Form
To: All Department Heads
From: Barbara Rudder
Date: December 9, 2008
Re: Workers’ Compensation Carrier Change effective 1/1/06
Please be advised that as of January 1, 2006, the Town of Southold is changing
our Workers Compensation carrier the New York State Municipal Workers’
Compensation Alliance. PERMA will no longer be the carrier for NEW CASES as
of January 1, 2006.
As in the past, all accidents and injuries occurring on the Town of Southold’s
property or involving entity-related activities must be reported to the Accounting &
Finance Department immediately. If a workers’ compensation claim is evident,
you must complete and return the attached “inquiry” document to this office as
soon as possible so that we can report the injury to the Comp Alliance within 24
hours. If this office is closed, please report the injury to the New York State
Municipal Workers’ Compensation Alliance claim reporting desk by faxing the
Inquiry report to (516) 227-2352.
Please contact me should you require any additional information.
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Town of Southold
Workers’ Compensation Injury Report
Fax to (631)765-1366; after hours, also fax to (516) 227-2352
EMPLOYEE NAME: SOC SEC #:
WORK LOCATION:
HOME ADDRESS:
CITY: STATE: ZIP:
OCCUPATION: DATE OF HIRE:
HOME TELEPHONE: DATE OF BIRTH: SEX:
DATE OF INJURY/ILLNESS: # OF DAYS OF WORK WEEK:
TIME OF ACCIDENT: AM/ PM TIME EMPLOYEE BEGAN WORK: AM/PM
ADDRESS WHERE INJURY/ILLNESS OCCURRED (INCLUDING COUNTY)
CITY: STATE
BRIEF DESCRIPTION OF INJURY/ILLNESS (Describe what happened and how it happened. Be
specific; identify tools, equipment or material in use at time of accident/injury occurred.)
IF INJURED, WHAT PART(S) OF THE BODY WAS/WERE AFFECTED?
DID EMPLOYEE GET MEDICAL ATTENTION? NO YES WHEN?
NAME AND ADDRESS OF DOCTOR AND/OR HOSPITAL
ANY TIME LOST FROM WORK? NO YES LIST DATE(S)
LIST ANY WITNESSES:
DATE/TIME SUPERVISOR WAS INFORMED OF INJURY/ILLNESS?
EMPLOYEE’S SIGNATURE : DATE:
DEPARTMENT HEAD SIGNATURE: DATE:
* DEPARTMENT HEAD: PLEASE INFORM EMPLOYEES TO ADVISE THE
ATTENDING PHYSICIAN THAT THIS A JOB RELATED INJURY/ILLNESS.
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