Form 122 - Employers First Report Of Injury Or Illness - 2009 Page 3

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FRAUD – “Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for
disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of
a crime and may be subject to fines and confinement in state prison.”
EMPLOYEE INFORMATION
INJURY/ILLNESS REPORT: A report of your injury/occupational illness must be made with your employer.
If a report of injury is not filed with your employer or the Labor Commission, Division of Industrial Accidents,
within 180 days of the date of your injury/illness, you may lose the right to ever file a claim for workers’
compensation benefits for that injury or illness.
EMPLOYER’S PHYSICIAN: If your employer has a company physician or designated clinic for industrial
accidents, you MUST see the company physician first, or you may not be eligible for workers’ compensation
benefits. After you have been seen by your employer’s physician, you have the right to choose one treating
physician.
MEDICAL COOPERATION: You must cooperate with your employer or the insurance carrier in following
prescribed medical treatment in order to return to work as quickly as possible.
TRAVEL REIMBURSEMENT: You may be eligible for travel reimbursement to and from approved medical
care. You will need to keep records. Contact your insurance carrier regarding travel expenses.
REEMPLOYMENT ASSISTANCE: You may be eligible for reemployment assistance if you are unable to
return to work due to an industrial injury. Contact your insurance carrier or the Labor Commission, Division of
Industrial Accidents, for further information.
MEDICAL EXPENSES: You are entitled to have all reasonable medical expenses paid that are a result of the
injury or illness.
COMPENSATION BENEFITS: You are entitled to 66-2/3 of your wages up to 100% of the state average
weekly wage (as of the date of your injury) after 3 days from the date of your injury, if a physician states you are
totally unable to work.
□ If you have sustained a permanent impairment due to the industrial injury or disease, you are entitled to
compensation based on the impairment rating as determined by a physician.
□ If you are permanently totally disabled from working due to the industrial injury, you may need to apply
at the Labor Commission, Division of Industrial Accidents, for a hearing to determine if benefits are due.
ADDITIONAL ASSISTANCE: If you are unable to work due to an industrial injury and meet the program’s
requirements, you may be eligible for other assistance. Agencies you may wish to contact:
□ Department of Workforce Services for food stamps, cash assistance, medical assistance, or employment
assistance.
□ Social Security for total disability benefits.
UNEMPLOYMENT BENEFITS: If you are able to work, but have been terminated from your job, you need to
apply at the nearest Department of Workforce Services employment office within 90 calendar days after you are
released from full-time work by your doctor.
Contact your insurance carrier if problems occur during your injury regarding payment of medical
bills or compensation benefits. If you need to know who your employer’s insurance carrier is, you may
ask your employer or contact the Labor Commission, Division of Industrial Accidents.
THIS IS AN IMPORTANT DOCUMENT TO MAINTAIN FOR YOUR RECORDS

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