Forms

Flexible Benefit Plan: List of Qualifying Events

State Health Plan Comparison of Employee Contributions 2018

State Health Plan Comparison at a Glance 2018

Health Insurance Claim (State Plan) PPO Plan or Indemnity Plan

Prescription Claim

Authorization Request Form - HIPAA - PPO Plan or Indemnity Plan

HIPAA Privacy Rule Information - check link

Fair Labor Standards Act(FLSA)

Telephone Reference Call

Health Examination Certificate

Termination of Employment

Employee Transfer Request

Employee Address/Phone Change

Vacancy Permit - Classified

Contract

Pre-Employment Worksheet

Resignation Form

Families First Coronavirus Response Act

Families First Coronavirus Response Act (Español)

First Report of Injury - for I-SS employees ONLY

Incident Investigation Form

Liberty Mutual Pharmacy Form - same form as Sedgwick

Sedgwick Pharmacy Form - same form as Liberty Mutual

Occupational Safety and Health Act (OSHA)

ESS First Report of Injury or Accident - for ESS employees ONLY

Workers' Compensation Frequently Asked Questions

1. Who is required to provide Workers’ Compensation coverage?
Any employer who employs three or more employees.

2. What must an employee do when an injury occurs?
Report the injury to the employer immediately and in any event within 30 days.

3. Who provides and directs medical treatment?
The employer or its insurance company, subject to any Commission orders, provides and directs medical treatment.  The Commission may permit the employee to change physicians or approve a physician of employee’s selection when good grounds are shown.  However, payment by the employer or carrier is not guaranteed unless written permission to change physicians is obtained from the employer, carrier, or Commission before the treatment is rendered.

4. When can reimbursement for sick travel be collected?
Employees are entitled to collect for mileage for medical treatment in Workers’ Compensation cases at the rate approved by the Industrial Commission, provided they travel 20 miles or more round trip.  Special consideration will be given to employees who are totally disabled.

5. At what rate of pay are compensation payments made?
66 2/3 % of the average weekly wage.

6. When will the first payment be made?
The first check is due on the 14th day following the injury if disability is documented as work related by a physician.  No compensation is due for the first 7 days of lost time unless the disability exceeds 21 days.

7. How long is the employee eligible to receive weekly benefits for days away from work? 
Until the employee is released to return to work by a physician.

8. What is permanent partial disability?
Total loss or partial loss of use of a member of the body or inability to earn the same wages in any employment as earned at the time of the injury.

9. Who determines permanent partial disability?
The Commission, based on the impairment ratings of physicians or evidence of consideration of wage earning capacity.