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WHAT EVERY EMPLOYEE SHOULD KNOW | What is Workers’ Compensation? Workers’ Compensation is an insurance program that pays an employee’s medical and disability income benefits for work- related injuries and diseases. _ WHAT SHOULD AN INJURED EMPLOYEE DO IMMEDIATELY FOLLOWING AND ACCIDENT? » Notify your employer at once. You cannot receive benefits _unless your employer knows you are injured. Bniployees’ miust report all injuries within forty-eight (48) hours after the injury. Ask your employer to complete the “Employer’s First Report and Employee’s Notice of Injury Report” form. Request a “Surgeon’s Report” form from your employer. - The treating physician must complete this form for all initial visits. If time is lost from the job because of your injury, you must complete an “Employee’s Claim for Compensation for Disability” form and submit it to the Division of Worker’s Compensation. SUBSECTION 258- FILING OF CLAIM (a), (b), & (c): (a) The first claim for compensation for an injury shall be filed in writing within sixty (60) days after the injury on forms to be furnished by the Commissioner. Such claims shall be filed at the office of the Commissioner or deposited in the mail properly stamped and addressed to the Commissioner or to any person whom the Commissioner may designate. Each claim shall be swom. to by the injured person or whoever acts in his/her behalf, and shall be accompanied by a doctors’ certificate stating the nature and probable extend of the disability,.or by death certificate. (b) Supplementary claims, if any, for protracted disability or for any additional compensation claimed, shall be filed in the manner directed by the Commissioner. (c) For good and reasonable cause shown the Commissioner may extend the time limit set by this section- Amended June 12, 1961. Title 24, Chapter 11, Subsection 257 (a) & ( b) NOTICE, BY EMPLOYEE, OF INJURY: REPORT BY EMPLOYER (a) By personal delivery or by mail, written notice of an accidental injury shall be given by the person injured or someone. in his/her behalf to the employer or any of his agents within forty (48) hours after the injury. In the case of an occupational disease notice shall be given by the person injured or someone in his/her behalf to the employer or any of his agents within thirty (30) days from the first distinct manifestation thereof. Such notice shall contain the name of the person, the nature of the injury or occupational disease, and when and where it occurred. Unless written notice of injury or occupational disease is given as above, _ or unless the employee’s immediate superior has actual knowledge of the injury or occupational disease, compensation may be denied. For reasonable cause shown, the Commissioner may accept written notice of the injury given later than forty-eight (48) hours, but not later than thirty (30) days, after the injury and in the case of an ., occupational disease, the Commissioner may accept written notice given later the thirty (30) days, but not later than ninety (90) days after the first distinct manifestation thereof: which time limit for filing of reports shall also be applicable to injuries of a tuberculous Origin arising out of employment. (b) Within eight (8) days after the receipt of the written. notice injury referred to in subsection (a) hereof, the employer shall complete an employer’s report of injury and forward same together with the employee’s notice of injury to the Commissioner by personal delivery or by mail. The failure of the employer to file ‘such reports with sucly period shall not prejudice the claim of the employee. BASIC BENEFITS AVAILABLE TO INJURED EMPLOYEES: Disability Income Benefits (Lost Wages) All injury/disease, medical expenses are paid directly to the health care provider. Rehabilitation Services Payments of Prescriptions Durable Medical Equipment Therapy and Chiropractic Services e Other related treatment pertaining to the injury/disease. All medical services are subject to prior written authorization. If you have any questions, please contact or visit the Division of Workers’ Compensation. St. Thomas: 2353 Kronprindsens Gade 53A/S54A&B St. Thomas, USVI 00802 (1-340-776-3700) St. Croix: 314.King St. Frederiksted, St. Croix 00840 nn (1-340-692-9390) EMPLOYER’S FIRST REPORT AND EMPLOYEE’S NOTICE OF INJURY OR OCCUPATIONAL ILLNESS CASE NUMBER VI DEPARTMENT OF LABOR, DIVISION OF WORKER’S COMPENSATION (NOT TO BE FILLED BY EMPLOYER) ST. THOMAS AND ST. CROIX 1. Employer (Company Name) 2. OSHA Case or File Number = 3. Mailing Address (No.. Street. City. Zip) 4. V.LE.S.A Account Number Sa Q = 5. ° Employer’s Location if Different from Mailing Address 6. Insurance Policy Number = <> 7. Nature of Business, Products Manufactured (Construction, Trade, Etc.) 8. Number of Employees 9. Employee’s Name (Fist. Middle, Last) 10. Social Security Number Il. AgeD.O.B 12. Sex a 13. Employee’s Mailing Address (No.. Street, City or P.O. Box. Zip) 14. How Long Employed? 15. Nationality? C = 16. Occupation 17. Department in which Employed 18. Name of Supervisor = 1 119. Hours worked per week 20. Days per week | 21. Wageperhour | 22. Salary per Wk/Mo. 23. If other Advantages Are Provided, Estimate Value Per Wk/Mo. (specify) 24. Place of Accident or Exposure (Address and Location) 25. State if Employer’s Premises 26. Department 27. Date of Injury 28. Day of Week 29. Time of Day AM 30. Date Supervisor First Knew of Occurrence 31. Did Employee Die? PM 32. Date Disability Began or Occupational 33. Time of Day AM 34. Was Insured Paid In Full This 35. Time of Day Employee Begins Work Illness Became Evident Day? PM 36. Activity of Employee at Time of Accident or Exposure (Be specific: If Using Tools or Equipment or Handling Materials. Name them and tell what employee was doing with them). 37. TYPE OF ACCIDENT that Occurred (Describe Events Fully: Name Objects or Substances Involved and How They Were Involved and How They were Involved: Give Full Details On All Contributory Factors). ACCIDENT OR EXPOSURE 38. Name and Addresses of Witnesses 39. SOURCE OF INJURY or Occupational Illness (Name Object Struck or Struck By: Vapor, Poison, Chemical; If Strain or Hernia, Name Thing Lifted or Pushed; If solely From Bodily Motion, Describe Twisting Resulting in Injury; Etc.) 40. NATURE OF INJURY or Occupational Illness or PART OF BODY Affected (E.G., Amputation of Right Index Finger, Lead Poisoning, Inflammation of Left Eye) OCCUPATIONAL ILLNESS 41.Name and Address of treating Practitioner 42. If Hospitalized, Name and Address of Hospital 43. If Employee Returned to Work, 44. At What Wage? 45. At What Occupation 46. Was Case Recorded on OSHA Long 200S Give Date and Hour REPORT PREPARED BY (PRINT OR TYPE NAME) POSITION TELEPHONE NUMBER EMPLOYER’S SIGNATURE DATE OF EMPLOYER’S SIGNATURE EMPLOYEE’S SIGNATURE EMPLOYEE’S TELEPHONE NUMBER | DATE OF EMPLOYEE’S SIGNATURE FORM NUMBER VIDSS:1-1-75 Workmen’s Compensation Form No. 2 SURGEON’S REPORT VIRGIN ISLANDS OF THE UNITED STATES oT ] The Patient STANDARD FORM FOR COMMISSIONER OF CABOR 1. Name of Injured Person: ............ eee eeeces eee e ee ececeens ose 2. Address: No. and St. 3. Name and Address of Employer . . » Commission's File:......... on Number Carrier: ...... eee eecee : . Co Carrier's File No... (The spaces above not to be filled in by Employer) oOo >>> eer oseoe . City or Town - +... Virgin Islands of U.S.A. eoves See eecnvee The Accident eee | ed The Injury | Treatment Disability eoererenesreoeeeeeeeeeeeean 7, ec eee eeweresrereeoseoe eoeeees 9. ° ee ee eeonvevacee . 10. eoee ew eoreeeooese 11. _Will the injury result in (a) Permanent defect? . 2.02 cece cc ccc oc olf SO, WHAE2. oc ec ee cw ccc n cnc ncnce (b) Facial or head disfigurement? ....... Is accident referred to the only cause of patient's condition? ............. If not, state contributing causes... ... eeenecee eoeoer nner eee eneeeee ey eoeeer ere ves eoeneese Give accurate description of nature and extent of injury and state your objective findings: .. 2... .e cee ee ences cewmeerecn eee eoemeoeereer oer eee eoreoeceensnece eew evens eesreeseeeevseseveeecevens eect eee ereereerwmeneeteeseserneeseece is patient suffering from any disease of the heart, lungs, brains, kidneys, blood, vascular system or any other dis- abling condition not due to this accident? .............-06- Give particulars: 2.0... cece cece ccees eeoeoe Ce ee Has patient any physical impairment due to previous accident or disease? .............» -Give Particulars:....... Has normal recovery been delayed for any reason? ........ +++ Give Particulars: . 01... eee e cece ceenee 11-b Name and type of medication prescribed for this injury .. 0... 2.02 cee cece eee eect eect eee etovcces 12. Date of your first treatment: . .. Describe treatment given by you: . eevee eceeecece Were X-rays taken? X-rays diagnosis:...... eseee eeoeocsore acoe Was patient treated by anyone else? ........By Whom?..... wee Was patient hospitalized? ...... ~ees..-Name and address of hospital:........ aeoe Oe eceneve eoeece cece weereceeccecse re Oe oe) . » «For how long? .. eeoveceee (Name ang Address) veecase When? occ eeeeceees eveeree eeeeeeoteooetoeoneere . Date of discharge: a ee eeoscweneceeeevoeseereoaeoee® STS, a Patient was/will be able to resume work on:. . er ee ey If death ensued give date: Patient was/will be able to resume work on:.........-.2- eeee eoeceecee ever eeoeeoe reer eceosesreeeces oor erereereeoeoeereeeoe ere? ee eoeoeoereoeneaeee eeoeoeecosrseoenereees eee? oor esreewes tam duly licensed physician in the State of ....... { was graduated from . eowveee eoerereeeeoneoe ese eooeoreeaeseeeevereooe Date of this Report:.......... This Report must be signed personally by physician. ewoeeee wee ee Signed:.... Address: ........- eoeoarsroenreseseoeaeneerere eoeteoeeoneereresevneseeeeee se eee se Medical School in ...... ccc cece cece VGF ec ceees eee erorcrserveeseseeeoere® wececccccee Pelaphone: ....eee Et CES IN = = | Saou = <7 — ape NZ, 18 NS NY U ~. Cand ad tte aaah 5 Fe Ki = Y ep \ G Va NLS, y) NX, wr IT Ken HT FT HT FT ARM CP o>———=. O20 /R ‘a | BACK | ‘, | ! ] FRON AL V » oT 6)