Checklist: Handling Claims and Collecting Information

The initial period is critical in handling workers' compensation claims. Be sure to:

• Administer first aid
• Accompany injured worker to a selected medical provider
• Report incident within organization
• Notify family
• Assign case manager or other responsible person to follow claim.

• Report to claim handler outside organization (insurance organization or third-party administrator)
• Determine, on a preliminary basis, whether the injury is covered by workers' compensation
• Contact union, if applicable
• Counsel employee and/or family on claims procedures, available benefits, organization's continuing interest in employee's welfare, etc.
• Follow up with the employee or family.

• Coordinate payment of initial benefits
• Talk to treating physician to learn diagnosis and treatment plan
• Evaluate whether medical rehabilitation is necessary or appropriate
• Develop return-to-work plan
• Forward mail
• Contact the injured employee and/or the family.

First month 

• Use a "wellness" approach (cards, phone calls, visits) to continue to reinforce organization's concern
• Consider medical examination by independent physician, if warranted
• Reevaluate treatment plan based on new medical information
• Update return-to-work plan
• Check for third-party involvement for possible Second Injury Fund recovery
• Contact the injured employee and/or the family.

Ongoing

• Continually reevaluate treatment plan
• Update return-to-work plan
• Refer for vocational rehabilitation
• Refer for pain management evaluation of chronic pain, if appropriate
• Maintain contact with the injured employee and/or the family.

• Name, nicknames, maiden name, previous names
• Address --current and previous (length of time living at both addresses)
• Phone number, pager number, cellular number
• Social security and driver's license numbers
• Sex
• Date of birth
• Marital status
• Dependents and immediate family contact
• Non-relative contact
• State hired and date of hire
• Job classification (insurance class or organization classification)
• Vehicle (type, year, license number)
• Interests --hobbies
• Length of time as a state resident.

• Time and date of injury
• Date of death (if applicable)
• State of injury
• Nature of injury (sprain, fracture, etc.)
• Body part(s) affected; any previous injury to the affected body part(s)
• Source of injury (machines, hand tools, buildings, etc.)
• Type of injury (fall, struck by, overexertion, repetitive motion trauma)
• Witnesses
• Work process involved (lifting, carrying, etc.)
• To whom was the injury reported
• Who filled out the first report of injury report
• Plant or location
• Department
• Supervisor
• Job
• Time and date the injury was reported
• Shift.

• Date employer first notified
• Who was notified, by whom?
• Date employer's workers' compensation claims department notified
• Date insurance organization or service organization notified
• Date state agency notified
• State case number
• Average weekly wage
• Benefit rate
• Health care providers
• Health care costs
• Other benefits lost (Did the employer stop paying vacation, health benefits, etc.?)
• Other benefits received
• Offset for other benefits
• Date disability started
• Date of first payment
• Projected return-to-work date
• Date case closed
• Date of maximum medical improvement
• Impairment rating
• Lost days
• Total benefits paid
• Reserves
• Vocational rehabilitation activity
• Subrogation (Is some third party responsible?)
• Second injury fund potential.

• conduct the interview in a nonadversarial setting
• demonstrate concern and empathy
• allow the worker to talk
• do not rush the worker
• reenact the accident
• check for photos and/or video of the accident.

• note the location where the statement is taken
• let the employee write the statement, if possible
• statement should be written in ink
• statement is taken ASAP after the injury
• describe the worker's preinjury and post injury actions
• request that the worker and any witnesses sign the statement
• make sure the employee initials any changes
• give copy of statement to employee
• list the date and time of the statement.

• Note witness' location at the time of injury
• record witness' relationship to the injured worker
• interview witnesses individually
• do not rush the witness
• make sure the statement is unrehearsed.

• make sure the witness writes the statement in ink
• record the statement ASAP after the injury
• make sure the witness records his/her actions before, during and after the time of injury
• request that the witness sign the statement and initial any changes
• record the date and time of the statement
• give a copy of the statement to the witness.