YOUR RESPONSIBILITES IF YOU ARE INJURED AT WORK
- Inform your supervisor - If you are injured on the job or diagnosed with an occupational disease, you must inform your supervisor immediately.
- Complete an Employee Incident Report. Not all employee incidents become workers' compensation claims, but all employee incidents need to be recorded to retain the facts of the injury and to gather information for loss prevention purposes.
If no medical attention is needed, stop here.
WHAT TO DO IF YOU NEED TO GO TO A MEDICAL PROVIDER
- Inform your supervisor you are seeking medical attention right away.
- Contact ESD 112 at (800) 749-5861 immediately to:
ESD 112 will send you a SIF2 claim form and packet of information to complete. Submit the SIF2 to the Safety/Risk Manager in Employee Services and return the completed packet to ESD 112 in the envelope provided.Should notice of your claim come from another source, such as from your employer or from a medical provider, expect a phone call from the ESD 112 workers' compensation claims staff.ESD 112 will investigate each claim within 24 hours of notification of an injury. Calls are placed to the injured employee, the employee's supervisor, and the initial medical provider. The purpose of these calls is to gather necessary information to determine eligibility for Workers' Compensation benefits.
- Report the incident has occurred
- Provide details of the incident to the claims staff
- Obtain a claim number
WHAT TO DO AT THE MEDICAL PROVIDER'S OFFICE
- Inform the medical provider that this is a work related incident and that your employer is self-insured and a member of the Southeast Washington Workers' Compensation Trust.
- Provide the medical provider with your claim number. If you do not have a claim number yet, call ESD 112 at (800) 749-5861 from the provider's office to obtain one
- Instruct the medical provider to forward all claim information and authorization requests to:
ESD 112 Workers' Compensation Claims Department
2500 NE 65TH AVE
Vancouver WA 98661-6812
Phone: (360) 750-7504 Fax: (360) 750-9836
- Complete the Provider's Initial Report- Provided by the medical provider. (Do not file an L&I State Fund claim form at the provider's office).
- Obtain a work status note from the attending physician to provide to your supervisor, Employee Services and ESD 112.
- Schedule a return appointment for follow up.
WHAT TO DO AFTER EACH MEDICAL PROVIDER VISIT
QUESTIONS? Contact Aubrey Pitzer, PSD Safety/Risk Manager (509) 543-6700 ext. 2349.
- Call ESD 112 to report your medical and return to work status.
- Fax your return to work status note within 24 hours to ESD 112 (360) 750-9836.
Report your return to work status to your supervisor within 24 hours and provide Employee Services and your supervisor with a copy of your work status notes.