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WHAT IS WORKERS’ COMPENSATION?
Workers’ Compensation is a University paid benefit for employees and students
that are working payroll or work study.
Workers’ Compensation is a form of insurance that provides compensation
medical care for employees who are injured in the course of employment.
Workers' Compensation is designed to ensure that employees who are injured or
disabled on the job are provided with fixed monetary awards, eliminating the
need for litigation.
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EMPLOYER’S RESPONSIBILTY
Along with providing workers’ compensation coverage, the employer must
perform some, if not all, of the following duties:
Post a notice of compliance with workers’ compensation laws in a
prominent place at each job site
Provide immediate emergency medical treatment for employees who
sustain an on-the-job injury
Provide immediate medical attention if an injured worker is unable to
select a doctor or advises the employer in writing of a desire not to do so
File a report of the injury and mail or fax it to the nearest workers’
compensation board office. A copy of the report should also be mailed to
the employer’s insurance company.
Create a written report of every accident resulting in personal injury that
causes a loss of time from regular duties beyond the working day or shift on
which the accident occurred or that requires medical treatment beyond
first aid or more than two treatments by doctor or persons rendering first
aid.
Accede to all requests for further information regarding injured workers by
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EMPLOYEES’ RESPONSIBILITY
If an employee should be injured on the job, the following steps must be
performed immediately:
1. If an injury occurs that requires immediate attention, seek medical
attention immediately.
2. Within 24 hours after the injury make contact with the Department Head.
3. Within 24 hours of the injury contact the following:
• Benefits Manager/Risk Manager: Cecilia Taft 466-3387
• Safety Officer: Darryl Hughes 466-3360
4. Written documentation from the employee through his/her immediate
supervisor must be submitted as soon as possible on or after date of injury.
5. Should the employee expect to be off the job for three (3) days or more,
both a Family Leave form and a Request for Leave from must be attached.
6. The forms indicated in #5 above, can be mailed to the employee’s home by
Human Resources if notified they are going to be absent and cannot come
into the office to pick them up.
7. The employee must choose which compensation method they want to use
and report it in writing to the Human Resources Office. See attached
information.
8. An employee cannot return to work until a release from the physician is in
the Human Resources Office.
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SUPERVISOR’S RESPONSIBILITY
If an employee is injured on the job, the following steps must be performed
immediately:
1. If an injury of an employee occurs that requires immediate attention, seek
medical attention immediately.
2. Within 24 hours of the injury of the employee contact the following:
• Benefits Manager/Risk Manager: Cecilia Taft 466-3387
• Safety Officer: Darryl Hughes 466-3360
3. Written documentation must be submitted as soon as possible on or after
date of injury.
4. If the employee is expected to be off the job for three (3) days or more, a
FMLA request for Family Leave form, doctor’s statement, and a Request for
Leave from must be attached.
5. The forms listed in item #4 above can be mailed to the employee’s home
once Human Resources is notified that the employee is going to be absent
for (3) days or more.
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WORKERS COMPENSATION INFORMATION
Should an employee need to seek medical attention at a hospital/doctor’s office or need the carrier information for a prescription it is as follows:
CompSource Oklahoma P.O. Box 53505 Oklahoma City, OK 73105
Their phone number is 1-800-347-3863 and as always, you can contact the Human Resource Office at (405) 466-2985
COMPENSATION OPTIONS FOR EMPLOYEES
Employees have two (2) options when it comes to payroll compensation.
1. Employee can be paid at 100% using accumulated sick leave (or other leave programs available at the University – if eligible)
2. Employee can be paid at 70% through CompSource Oklahoma.
Should an employee choose not to use accumulated leave, then a letter stating such should accompany this packet. Also, with the completion/approval of the FMLA form, the employee’s health benefits will continue for up to twelve (12) weeks. It will be the responsibility of the employee to continue the premium payments as long as they are compensated through CompSource Oklahoma after the twelfth (12) week. Should there be a lapse in coverage during this time the employee will not be allowed to re-enroll with the health insurance carrier for twelve (12) months.
Please sign this form stating that the Benefits Manager discussed the options available to employees.
_________________________________ _______________________
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WORKERS COMPENSATION INFORMATION
________________________________ _________________________ ______________________________________________________________________________ _______________________ _______________________ ______________________ ________________________________ ______________________________ ________________________________ _________________________ ________________________________ _________________________ ________________________________ _________________________ ______________________________________________________________________________ SINGLE INCIDENT: (SPRAIN, STRAIN, BURN, ETC)
______________________________________________________________________________ IDENTIFY PARTS OF THE BODY INVOLVED & DESCRIBE ACTIVITY AT TIME OF INJURY:
______________________________________________________________________________ ______________________________________________________________________________ IS THIS A CONTESTED CLAIM? YES NO
FULL NAME (LAST, FIRST, MIDDLE) SOCIAL SECURITY #
COMPLETE ADDRESS CITY STATE ZIP
TELEPHONE # DATE OF BIRTH GENDER
LENGTH OF EMPLOYMENT OCCUPATION
DATE OF ACCIDENT/TIME TIME WORKDAY BEGAN
AM / PM AM / PM
DATE EMPLOYER NOTIFIED PLACE OF ACCIDENT
LATEST DATE EMPLOYEE WORKED DATE RETURNED
NATURE OF ILLNESS: (DIAGNOSIS)
PAGE 8 ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Was employment agreement made in Oklahoma?
What is the average weekly wage for this employee? Policy # 00121778-01-1 SIC# 8221
SUPERVISOR SIGNATURE DATE
SAFETY OFFICER SIGNATURE DATE
BENEFITS MANAGER/RISK MANAGER SIGNATURE DATE
FOR OFFICE USE ONLY
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Workers’ Compensation
Supervisor Claim Reporting Information
EMPLOYER
Company Name: LU Worksite Location ________________________________ Supervisor Telephone Number_______________________________________________ Supervisor’s Name__________________________ Dept______________________
EMPLOYEE
Name
Home Address
Home Telephone Number Social Security Number
Date of Birth_______________ Male Female Date to Hire__________________ Title_________________________________________ Prof. Code___________________ Last Date Worked_______________________ Return to Work Date___________________
Accident Information
Date & Time______________________ Place_______________________________ Where Accident Occurred___________ Began Work Day at Work Date__________ Description of Accident_____________________________________________________ ______________________________________________________________________________ Description of Injury_______________________________________________________ ______________________________________________ Was Injury Fatal YES NO
Was Safety Equipment Provided and Used_____________________________________ How Could This Accident Have Been Prevented? ________________________________ ______________________________________________________________________________
Witness(es) Name, address & daytime telephone_______________________________ ______________________________________________________________________________ ______________________________________________________________________________ Please forward for signatures:
_____________________________ ____________________________ ____________________________ Department Head
Benefits Manager/Risk Management
