Please submit the following forms within 7 days of filing a new First Report of Injury:
- CMS Legal Documentation (to ensure compliance with federal Medicare requirements)
- Supervisor’s Report of Injury (used as a loss control and claims mitigation tool)
- Employee’s Report of Injury (used as a loss control and claims mitigation tool)
- Medical Release Form (necessary for the Trust to access employee’s medical records)
The above forms must be e-mailed (email@example.com) or faxed to (207)622-6804
Once the Trust has received and processed the First Report, we will e-mail a wage statement and fringe benefits form to you with the injured employee’s information.
Please complete within 7 days of receiving them.
- Wage Statement (to ensure compliance with WCB’s lost time determination - allows Trust to calculate the Average Weekly Wage)
- Fringe Benefits (WCB mandated this form in 2013 to detail the cost of any fringe benefits paid by the employer at the time of the injury)
The above forms must be e-mailed to firstname.lastname@example.org
If you or your employee has received any medical records, M-1’s, or bills pertaining to the injury, please send them to us immediately.
This is very important; please do not assume that we have anything. If you or the employee has received them, that means the Trust most likely has not.
- Bill, Medical Records, M-1’s
- Updates (verbal or written) from the injured employee, supervisor, witnesses, physicians, etc. that gives additional information on the disposition of the claim/injury
- If injured employee has notified you of an injury and they take time off or earn less than their pre-injury Average Weekly Wage, notify the Trust regardless of whether it is related to work or related to the work injury
- Any changes to the employer paying fringe benefits that were in place at the time of the injury
The above information must be e-mailed (email@example.com) or faxed to (207)622-6804