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Workers' Compensation Forms
1. Reporting an On-The-Job injury
Employee must report any work-related injury to his/her supervisor before the end of shift.
Employee completes and signs Part A of the University Injury or Illness Incident Report and their supervisor completes and signs Part B. Fax completed form to ext. 3650 or mail to the Main Campus Workers’ Compensation Office, Mail Stop 220 as soon as possible. This form must be completed to process any subsequent Workers’ Compensation claim.
2. Initial Treatment
If the injury is serious and requires immediate attention, the injured worker may go to any emergency facility such as The University of Toledo Medical Center. For non-emergency treatment, the injured worker may go to any BWC certified physician such as the Student Medical Center or Promedica Occuhealth.
We suggest choosing a provider both certified by Bureau of Workers’ Compensation and the employee’s health insurance carrier.
If possible, the employee should present the Health Management Solutions Workers’ Compensation Identification Card to the initial treatment facility.
3. Filing a Workers' Compensation Claim
A Workers’ Compensation Claim packet may be obtained from the Main Campus Workers’ Compensation office located in Room TC1410 or download forms from the menu to the right.
Included in the packet are:
- · University of Toledo Injury and Illness Incident Report Form
- · Health Management Solutions Workers’ Compensation Identification Card
- · Health Management Solutions Employee Handbook
- · Bureau of Workers’ Compensation First Report of Injury Form (FROI)
- · Medical release form
Return the completed forms to the Main Campus Workers’ Compensation office in Room TC1410, fax 3650, or e-mail Brenda.firstname.lastname@example.org. Some providers will forward the paperwork for you.
Please complete the employee/injured worker sections thoroughly as the information is used to assist in determining entitlement of Workers’ Compensation benefits. The completion of these forms does not guarantee entitlement of benefits.
4. Managed Care Organization (MCO)
The Managed Care Organization for the University of Toledo is Health Management Solutions. The Identification card should be presented to the provider rather than private insurance cards. A caseworker will be assigned to the injured worker to monitor the claim, authorize appropriate treatment, and payment of medical expenses.
Main Office - Phone: 1-888-202-3515 Fax: 1-888-303-6294
Local Office – Phone 419-536-5690 Fax: 419-536-7115
5. Lost Work Time
Any absences due to a work injury must be reported to the supervisor immediately. Be sure to clarify the absence is due to a work injury and not “sick.” Supervisor should contact the Workers’ Compensation Specialist at ext. 3655 or by e-mail Brenda.email@example.com to report the absence.
The injured worker should contact the Workers’ Compensation Specialist to discuss available wage compensation options.
6. Return to Work Programs
The University will make every effort to provide reasonable accommodations for injured workers who are unable to perform his/her regular duties yet able to perform modified or restricted duties. Contact the Workers’ Compensation Specialist for more details on return to work options.