| This
form is to be provided to ALL EMPLOYEES with job related
injuries |
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| IMPORTANT
INFORMATION! |
 |
WHEN
INJURED: To protect your claim, notify your Supervisor
of ALL incidents no matter how minor they may seem at the
time. A C-1 Form should be completed, signed by your
supervisor and forwarded to Human Resources. Please retain
a copy for your records. |
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|
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GO
TO THE DOCTOR IF NECESSARY: Employees and volunteers
are expected to use the County's designated physician(s) or
hospital(s) whenever possible. Be sure to inform the treating
physician that your injury is work related. The doctor's office
will complete a C-4 Form at the time of your visit.
(they may fax a copy to our office 782-9083) Retain a copy
for your records. |
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INSURANCE
ADMINISTRATOR: We are not insured through SIIS or
Employers Insurance Company of Nevada, physicians should forward
their forms to our office or WILLIS ADMINISTRATIVE SERVICES
CORPORATION. For further details they may contact Human Resources
at 782-9860. |
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|
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TIME
OFF WORK: A Medical Release Form is required from
your doctor for any time off work or restricted (light duty)
work. The form should state the date of your first day
off work and the estimated date you will return to work.
This original notice should come to our office. Without
the C-4 and the Medical Release Form no compensation check
can be prepared! |
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|
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FMLA:
Employees placed off work for three or more days industrial
injuries will automatically be placed on FMLA (Family Medical
Leave). For further details on FMLA please refer to policy
#02.02.20 or contact Human Resources. |
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LIGHT
DUTY: Active employees get well faster; Douglas County
will encourage light duty. If the "Return to Work Release"
is for light duty, the physician must specify all work
restrictions and these instructions must be followed by the
injured employee. |
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|
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TURN
IN FORMS: Bring all forms to the Human Resources Department
immediately. Human Resources will forward the forms
to the necessary location. Following these guidelines will
help to assure prompt coverage on your industrial injury. |
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| WILL
I RECEIVE DISABILITY WAGES? |
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If
an employee is off work one to four (1- 4) full work days
ONLY, they will be required to utilize their sick leave
benefits to receive regular compensation. |
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|
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If
an employee is off five (5) or more consecutive days
and the claim is accepted, our carrier may pay 66 2/3 of the
employee’s deemed wages, retroactive to the first day
employee is off work, per NRS. |
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To
speed your payment, once your claim is approved, you may receive
a check from County payroll then, |
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Your
PACT check will come via the Human Resources office unless
otherwise stated; upon receipt you will be required to sign
it over to the Payroll Division. |
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To
utilize your sick leave to receive compensation for the one-third
(1/3) lost pay, you must sign a AUTHORIZATION TO REDUCE
SICK-LEAVE FORM for the Payroll Division. |
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| INSURANCE
ADMINISTRATOR: |
| |
Willis
Administrative Services
Phone (775) 329-1181
1755 E. Plumb Lane, Suite 267
Reno, NV 89502 |
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| STILL
HAVE QUESTIONS? |
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Call
Human Resources at 9860 or refer to POLICIES & PROCEDURES
#02.02.17.04. Thank you. |
