WORKER'S COMPENSATION NOTICE
Your employer is required to provide for payment of benefits under the Worker's Compensation
Act of the State of Indiana.
Any employee who is injured while at work should report the injury immediately to their
supervisor, employer, or designated representative.
The worker's compensation insurance carrier or the administrator for
________________________________________
is: ______________________________________
(name of company)
(name of insurance carrier or administrator)
__________________________________________________________________________
(name of carrier/administrator)
_________________________________________________________________________
(mailing address)
_________________________________________________________________________
(city, state, zip)
_________________________________________________________________
(telephone number)
________________________________________________________________________
(contact person)
For more information about rights or procedures under the Indiana Worker's Compensation
system, call or write:
Worker's Compensation Board of Indiana
Ombudsman Division
402 W. Washington St., Rm W196
Indianapolis, IN 46204
(317) 232-3808
1-800-824-2667
Indiana Worker's Compensation Board 04/21/05