Employee Right - Worker’s Compensation

Worker's Compensation is the state regulated insurance program that pays medical bills and replaces a portion of lost wages for employees who are injured at work, or who have work related illnesses. Worker's Compensation also prohibits an employer from firing the employee, because he or she filed for Worker's Compensation.

Worker's Compensation is compromise based, where the employer provides for the continued income and medical care, while the employee does not sue the employer or ask for outrageous damages.

Worker's Compensation laws are enforced and administered by State's Workers ' Compensation Commission, board, or a comparable agency.

	Injured Employee's Name
	Injured Employee's Social Security Number
	Injured Employee's Mailing Address
	Injured Employee's Home or Work Phone Number
	Date of Birth
	Date of Injury/Disease
	Gender
	Occupation or Job Title
	Description of Accident
	Type of Injury/Disease and Part(s) of Body Affected
	Employer Policy Number

	Employee injured himself/herself while in a state of intoxication;
	Employee willfully attempted to injure themselves or unlawfully injure another person;
	Employee was injured for a personal reason by someone who was not a co-worker;
	Employee was injured while participating in a voluntary off-duty recreation, social, or athletic activity that was not part of the employee's duties;

Employers have certain responsibilities when the employee suffers on the job injuries.

	Employers are responsible to carry worker’s compensation.
	All medical bills payment because of work related injury.
	Payment of benefits as a substitute for lost wages.
	Employer is responsible to pay the permanently incapacitated employee lump sum amount.
	Employer is responsible for the payment of death benefits.