CAMPUS WHAT TO DO WHEN THERE IS AN INJURY ON THE JOB

Campus What To Do When There Is An Injury On The Job-PDF Download

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Verification of Employment for a Reported Workers Compensation. Injury or Illness, Please take this form to the doctor for your first medical examination. Employee Name Date of Injury,Date of Birth Social Security. Reported Work Related Injury or Illness, Midland ISD workers compensation coverage provider is the Texas Association of School Boards Risk. Management Fund which is a member of the Political Subdivision Workers Compensation Alliance the. Alliance For emergencies an injured employee may go to the nearest emergency room Otherwise all other. treatment must be from an your School District s WC Doctor Nova Medical Center 2501 W Illinois Midland. Please submit all claim and medical billing information to. TASB Risk Management Fund,PO Box 2010,Austin TX 78768 2010. Phone 800 482 7276,Fax 800 580 6720,Pre Authorization.
Phone 800 482 7276 ext 9907,Fax 888 777 8272,Issuing Signature Title. Phone Number Date, Providers please submit Work Status Reports and all Job Description enquiries to. The Benefits Department,Email benefits midlandisd net. Phone 432 240 1950,Fax 432 689 5869,Midland ISD Campus WC Instructions Page 2. FORM TO ELECT LEAVE BENEFIT S WITH WORKERS,COMPENSATION NO OFFSET ENGLISH VERSION.
Name Employee number,Position Department Campus, This employee is absent from duty because of a job related illness or injury beginning on date of first. absence attributable to illness or injury If eligible workers compensation insurance may begin paying. a percentage of the employee s current wages on the eighth day of absence from duty if an extended. absence is required,District Authorized Signature Date. Employee choice, I am absent from duty because of a job related illness or injury I understand that I am not eligible for. workers compensation weekly income benefits until my absence exceeds seven calendar days I also. understand that the district will continue to pay its contribution toward the cost of my group health. insurance coverage if applicable as long as I am on paid leave and or family and medical leave. FMLA I further understand that I will be responsible for paying all health insurance premiums if I am. on unpaid leave that is not FMLA leave I choose the following option. I choose to use only days of available paid leave at this time. I choose to use all available paid leave I understand that I will not receive workers. compensation weekly income benefits until I have exhausted all of my paid leave or to the extent. that paid leave does not equal my pre illness or injury wage. I choose not to use any available paid leave at this time I understand that I will not receive any. regular salary payments from Midland ISD while receiving weekly income benefits under. workers compensation No available paid leave will be deducted from my leave balance I. further understand that by selecting this option I will receive only workers compensation wage. benefits for any absences resulting from my work related illness or injury unless and until I. communicate to the district a change in my decision. Employee Signature Date,For Claims Reporting Purposes Only. For all employees For hourly employees only,Amount of leave paid to employee Hourly rate.
Daily rate Number of hours paid,Period of payment from. through for days or, 9 16 2016 Texas Association of School Boards Inc All rights reserved. Midland ISD Campus WC Instructions Page 3,FORM TO ELECT LEAVE BENEFIT S WITH WORKERS. COMPENSATION NO OFFSET SPANISH VERSION,Nombre Numero de empleado. Posicion Departamento Campus, Este empleado est ausente de su trabajo debido a una enfermedad o lesi n relacionada con el trabajo que.
comenz en fecha de la primera ausencia que se atribuye a enfermedad o lesi n Si es elegible el. seguro de compensaci n de los trabajadores puede comenzar a pagar un porcentaje de los salarios. actuales del empleado en el octavo d a de ausencia del trabajo en caso de que se requiera una ausencia. prolongada,Firma autorizada de distrito Fecha,Eleccion del empleado. Estoy ausent del trabajo debido a una enfermedad o lesi n relacionada con el trabajo Comprendo que no. soy elegible para los beneficios de ingreso semanales de compensaci n para trabajadores hasta que mi. ausencia exceda los siete d as calendario Tambi n comprendo que el distrito continuar pagando su. aporte hacia el costo de mi cobertura de seguros m dicos si es aplicable siempre y cuando estoy en. licencia con goce de sueldo y o licencia familiar o m dica FMLA Asimismo comprendo que ser. responsable de pagar todas las primas de seguros m dicos si estoy en licencia sin goce de sueldo que no. sea una licencia FMLA Elijo la siguiente opci n, Elijo utilizer solamente dias de licencia disponible con goce de sueldo en esta oportunidad. Elijo utilizar todas las licencias con goce de sueldo disponibles Comprendo que no. recibir losbeneficios de ingresos semanales de compensaci n de los trabajadores hasta. que haya acabadotoda mi licencia con goce de sueldo o hasta en que la licencia con goce. de sueldo no es equivalentea mi sueldo previo a la enfermedad o a la lesi n. Elijo no utilizar la licencia con goce de sueldo disponible en esta oportunidad Comprendo que. norecibir pagos de salario regulares de Midland ISD mientras reciba los beneficios de. ingresosemanales conforme a la compensaci n de los trabajadores No se deducir la licencia con. goce desueldo disponible de mi saldo de licencia Asimismo comprendo que al seleccionar esta. opci n recibir solamente los beneficios de salario de compensaci n de los trabajadores para las. ausenciasque deriven de mi enfermedad o lesi n relacionada con el trabajo a menos y hasta que. comuniqueal distrito un cambio en mi decisi n,Firma del empleado Fecha. For Claims Reporting Purposes Only,For all employees For hourly employees only. Amount of leave paid to employee Hourly rate,Daily rate Number of hours paid.
Period of payment from,through for days or weeks, 9 16 2016 Texas Association of School Boards Inc All rights reserved. Midland ISD Campus WC Instructions Page 4,Midland ISD Campus WC Instructions Page 5. Midland ISD Campus WC Instructions Page 6,Midland ISD Campus WC Instructions Page 7. Midland ISD Campus WC Instructions Page 8,Midland ISD Campus WC Instructions Page 9. Midland ISD Campus WC Instructions Page 10,Midland ISD Campus WC Instructions Page 11.
workers compensation weekly income benefits until my absence exceeds seven calendar days I also understand that the district will continue to pay its contribution toward the cost of my group health insurance coverage if applicable as long as I am on paid leave and or family and medical leave FMLA I further understand that I will be

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