Work Comp Medical Form - City Of Watertown

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CITY OF WATERTOWN
MEDICAL SERVICE FORM
Name of Injured Employee:
Date of Injury:
Nature of Injury:
The above named employee has reported an injury occurred while at work for the City of Watertown.
Please forward all bills to the City of Watertown’s Workman’s Compensation insurance carrier at:
United Heartland, Inc.
PO Box 3026
Milwaukee, WI 53201-3026
Fax: (262) 787-7701
Please reference policy number #090003112
The City of Watertown is committed to preventing workplace injuries, controlling injuries that do occur, and
providing modified duties after an injury. The City offers many types of alternative work and/or transitional
work assignments which allow an injured employee to work within their medical restrictions. Our belief is that it
is in the best interest of the City of Watertown and our employees to return to work as soon as an employee is
physically able. Working together with the physician, injured employees can heal and return more quickly to
productive employment.
On the other side is a “Physicians Return to Work Recommendations” form to list any applicable medical
restrictions. Please complete this form and give it to the employee. After treatment, the employee should
return this form the Office of the City Clerk/Treasurer.
If you have questions regarding this injury or alternative duties available, please contact me.
Thank You,
Elissa Meltesen, Deputy Clerk/Treasurer
City of Watertown
106 Jones Street
PO Box 477
Watertown, WI 53094-0477
Phone: (920) 262-4007
Fax: (920) 262-4016
E-mail:

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