Workers’ Compensation Claims Reporting
What do I do after a Workers’ Compensation accident occurs?
• Secure medical treatment for your injured employee. If during normal business hours, use an Occupational Medicine Clinic instead of an emergency room. The cost savings can be significant. If you need assistance locating a clinic, please contact us at 1-877-257-2743.
• If possible, have the injured employee complete an Employee Accident Report Form before seeking treatment, to gather information about the accident in the injured employee’s own words.
• Management personnel on premises at the time of the incident should complete the Supervisor’s Accident Investigation Form to gather the facts surrounding the incident including any witnesses to the incident.
• If you have a drug/alcohol screening policy in effect, have employee submit to a post-accident drug/alcohol screen as soon as the injury is reported to you, even if the accident occurred several days prior.
• If injured employee refuses drug/alcohol screening or medical treatment, have employee complete the appropriate refusal forms.
• Report the claim by phone to LRA/SIF Claims Management at 1-877-257-2743 or on line at www.lraclaims.com as soon as possible following the injury/accident.. After reporting the injury/accident, the Intake Operator will provide you with an LRA/SIF Claim Number. Referencing the Claim Number will help expedite the handling of the rest of the claim. Please include the Claim Number with all future correspondence, such as wage statements, medical bills, etc.
• Forward a copy of the employee’s LA OWCA Second Injury Board Knowledge Questionnaire to the LRA/SIF claims office by fax to (504) 888-9033.
• If your employee is not able to return to work full duty immediately following an injury/accident, cooperate with the LRA/SIF to identify modified or transitional duty work where appropriate. Modified or transitional duty work helps the employee recover more quickly, both mentally and physically and can mean tremendous cost savings on your workers’ compensation claim.
Should you have any questions or concerns, please contact the LRA/SIF Claims office at the telephone
number above for assistance with the claim.
Louisiana Restaurant Association Self Insurer’s Fund
EMPLOYEE ACCIDENT REPORT
EMPLOYEE INFORMATION
Name____________________________________________________ SSN#_________________________
Address_________________________________________ City______________ State_____ Zip_________
Sex M F Date of Birth_______________ Age_____ Home Phone_____________ Cell____________
Job Title___________________________ Department___________________ Full Time____Part Time____
ACCIDENT INFORMATION
Accident Date__________________ Time____________ am pm Time Shift Began___________ am pm Location of accident
(Be Specific______________________________________________________________
What were you doing before the accident occurred?_____________________________________________
______________________________________________________________________________________
Explain how the accident occurred__________________________________________________________
______________________________________________________________________________________
Was this part of your normal job duty? Explain________________________________________________
Were you wearing any personal protective equipment (PPE)?
(gloves, mask, etc..)If so please list____________
___________________________________________________ Should you have worn PPE? Yes No Indicate the part(s) of your body affected or injured_____________________________________________
______________________________________________________________________________________
Person to whom the accident was reported_____________________ When reported___________________
List all witnesses to the accident____________________________________________________________
______________________________________________________________________________________
By my signature below I attest that the information contained on this form is true to the best of my knowledge and that no false statements were made or given when completing this form.
SIGNATURE OF EMPLOYEE:____________________________________DATE___________________
SUPERVISOR'S ACCIDENT INVESTIGATION REPORT
Company Name______________________________Address______________________________________
Name of Injured Employee_____________________________________ SSN#_______________________
Address_________________________________________ City______________ State_____ Zip_________
Date of accident_________Time______am pm Was employee on duty at the time of accident? Yes No Was employee on company premises? Yes No Describe accident in detail_________________________
________________________________________________________________________________________
Part(s) of body injured______________________________________________________________________
Did employee leave work? Yes No Date____________Time________am pm Did employee return to work? Yes No Date____________Time _______am pm
Did employee seek medical attention? If so, name/phone of provider_________________________________
ANALYSIS
Was the accident investigated? Yes No Do the facts indicate the injury was work related? Yes No What were the causes of the accident?__________________________________________________________
_________________________________________________________________________________________
Was a piece of machinery, equipment or guard the reason for the injury? If so, explain____________________
_________________________________________________________________________________________
Could employee have avoided being injured?
(Wearing Safety equipment, using guards, etc…)If so, explain____________
_________________________________________________________________________________________
What preventative measures can be taken to prevent future recurrence?________________________________
_________________________________________________________________________________________
Should this claim be questioned? If yes, why_____________________________________________________
________________________________________________________________________________________
List all witnesses to the accident______________________________________________________________
________________________________________________________________________________________
Supervisor’s Signature_______________________Accident reported to me: Date_______Time_____am pm
Louisiana Restaurant Association Self Insurer’s Fund
WITNESS REPORT
Today’s Date _________ Name ________________________________
Telephone/Cell_____________________
Email _______________ Address _____________________________________________________________
Witness to event of ___________________________________________________ Date of event _________
In your own words, state actual facts that you saw or heard:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
What did you witness immediately prior to the incident?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What did you witness during the actual incident?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What did you witness after the incident?
__________________________________________________________________________________________________
__________________________________________________________________________________________
If you actually saw the entire event, what do you feel to be the cause of the incident?
__________________________________________________________________________________________
__________________________________________________________________________________________
Signature __________________________________ Date ______________________________
Please write on back if you need more room
Employer’s Name &
Address:__________________________________________________________
Member/Policy #: ____________ Contact Person:_____________________ Phone #:______________
Employee’s Name & Address:__________________________________________________________
Employee’s Phone #:_________________ Date/Time of Accident:_____________________________
CHECK HERE IF: £ POST ACCIDENT DRUG / ALCOHOL TEST SHOULD BE CONDUCTED I, the undersigned, authorize any physician, physician’s assistant or nurse who has attended me, or any hospital at which I have been confined, to furnish to any authorized representative of LRA/SIF Claims Management, any and all information which may be requested regarding my condition and/or treatment, and to allow them to examine and copy any radiographic pictures or records regarding my condition or treatment. I specifically authorize said physicians, nurses and hospitals to communicate said information by any reasonable means, including written or telephonic communication or by direct interview, whether or not I am present during or notified of such communications, and I hereby authorize LRA/SIF Claims Management to initiate and conduct such communications whether or not I am present or have notice thereof. A photostatic or faxed copy of this release is to be given the same force and effect as the original.