Notice to Employees
The name, address and telephone number of your Workers' Compensation Company is:
Amtrust North America
P.O. Box 94405 Cleveland, OH 44101
Phone: (888) 239-3909
Policy Effective Date: July 1, 2020 through June 30, 2021
Employee: Reporting a Claim
Please follow the steps below within 24 hours of your workplace injury:
Declining Medical Treatment After A Workplace Injury:Under the Pennsylvania Workers' Compensation Act, you have 120 days to file a claim until you can no longer receive workers' compensation benefits. If your injury is minor and you decline to seek medical treatment after a workplace injury, complete and return the below forms within 24 hours of the incident. Your report form will be kept on file in the event that you need to seek medical treatment and file a claim. Forms may be emailed or faxed to Michele Zimmerman at 610-562-2634:Recording Absences
- If the injury is deemed to be a medical emergency an ambulance will be called for transport. Otherwise, an emergency contact should be called if transportation to an urgent care center is required and you are unable to drive yourself.
- REPORT THE INJURY TO YOUR SUPERVISOR & TO HUMAN RESOURCES PROMPTLY! If medical supplies are needed for minor injuries please obtain them from a First Aid kit or from the school nurse. Please do not REPORT your injury to a school nurse or seek medical evaluation/treatment from a school nurse.
- Complete the Employee Statement of Injury or Illness Form
- Complete the Employee Acknowledgement Form
- Complete the Authorization for Medical Records & Reports Form
- If you need to seek medical attention, OBTAIN MEDICAL CARE FROM A DESIGNATED MANAGED CARE PHYSICIAN.
You must treat with a managed care professional for a period of ninety (90) days. Except in extreme emergency, if you go to a non-panel provider the bills may not be covered by Workers' Compensation. If a panel provider refers you to another physician, bills will be covered.
- For the first 7 calendar days - absences following your initial physician evaluation should be recorded as sick time using the applicable absence code/method available to you.
- Beginning with the 8th calendar day - record absences using the available workmans' compensation code in our absence management system(s). In most cases accrued sick time is deducted.
Supervisor: Reporting a Claim
When notified of a workplace injury, please follow the steps below promptly:
- Depending on the severity of the situation, call an ambulance, call / ask the employee to call an emergency contact, or refer the employee to a Panel Physician. Staff are not permitted to transport an employee to a hospital or an urgent care center.
- Notify Michele Zimmerman (first point of contact) or Carlie Cole of the injury that occurred.
- If necessary, print the Incident Report Packet and provide to the injured worker to complete.
- Complete the Supervisor Accident Investigation Report.
- Ask any "witnesses" to complete the "Witness" Statement of Injury or Illness.
- Forward all completed forms to Michele Zimmerman or Carlie Cole within 24 hours of the incident.
Workers' Compensations Documents
- Authorization for Medical Records & Reports Form - NEW
- Employee Statement of Injury or Illness Form
- Medical Treatment Waiver Form - submit only if waiving medical treatment initially
- Notification to Employees of their Rights & Duties
- Physician Panel List
- Supervisor Accident Investigation Report - NEW
- "Witness" Statement of Injury or Illness - NEW
Map to St. Luke's Urgent Care Center - the closest emergency clinic to Hamburg Area School District
9 Dave's Way, Hamburg, PA 19526
In Pennsylvania, any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact materials thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.