Employee Training Verification Form printable pdf download

Texas

First Health/Travelers Health Care Network (“HCN”)

Employee Training Verification Form

Employer Name (Print or Type):_________________________________________________

Mailing Address:_____________________________________________________________

Employer Email Address:

______________________________________________________

Travelers Workers’ Compensation Policy Number: _______ - __________ -__ - ____

(Example: TCUB-1234A56-1-06)

Employer Requirements:

Employer named above has distributed the Health Care Network Employee Notice and the

Employee Acknowledgement Form on the Distribution Date shown below to each of its

current employees located in the Network Service Area. Employer named above has

collected the signed Employee Acknowledgement Forms and is keeping such forms on file as

required under Texas law. Employer named above will also distribute the same Health Care

Network Employee Notice and Employee Acknowledgement Form to each new employee

hired after the Distribution Date shown below. In addition, the Employer named above will

provide a copy of the Health Care Network Employee Notice to an injured employee at the

time that it receives active or constructive notice of an injury.

Distribution Date: MM/DD/YYYY___________________________ (Example: 03/21/2012)

Name of Employer Representative (Print or Type):_________________________________

Title:

By signing below, Employer Representative acknowledges that the Employer Requirements

for HCN enrollment as listed on the Employer Health Care Network Enrollment Checklist

have been completed.

Signature of Employer Representative: __________________________________________

Signature Date: ________________________________________

Phone Number (incl. Area Code) of Employer Representative: (____) ____ - ____________

Send this completed Employee Training Verification Form to Travelers:

By fax to:

1-800-397-0794 or

By e-mail:

By mail to:

Travelers - HCN Coordinator

P.O. Box 660456

Dallas, TX 75266-0456

Date received by Travelers:________________________

Note: If the Employer Named above has places of business located outside the

current Network Service Area, then please check the following box……………………….

Employee Training Verification Form