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ID #: Department Name: Date of Accident: Office Location: Time of Accident: Office Phone #: Place of Accident: Employee s Description of Accident (Include Cause of Injury): Part of Body Affected: Injury/Illness that Occurred: Injured Employee s Signature: Supervisor Supervisor s Name: Supervisor s Signature: Agree with Description of Accident? Office Phone #: Yes No Office Location (Bldg # & Room #): Keep a copy in your office, and send original.

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Workplace compensation legislation places liability on employers for any injuries their employees suffer at work, and ensures that victims of accidents at work are adequately compensated for loss in income or work capacity.

If you get hurt on the job, your employer is required by law to pay for workers' compensation benefits. You could get hurt by: One event at work. Examples: hurting your back in a fall, getting burned by a chemical that splashes on your skin, getting hurt in a car accident while making deliveries.

The FECA provides workers' compensation coverage for employment-related injuries and occupational diseases. Benefits include payment for medical care, wage-loss replacement, survivor benefits, and vocational rehabilitation assistance for return to work efforts.

The law requires employers to provide compensation for injuries that are work-related, regardless of fault. This means that even if the employer was not at fault, the employee is still entitled to benefits.

Here are some of the most common injuries, based on EMPLOYERS® claim data: Lacerations. Deep cuts or tears in skin or flesh. ... Sprains and strains. Sprains are stretched or torn ligaments, while strains are stretched or torn muscles and tendons. ... Contusions. ... Burns. ... Eye Injuries. ... Fractures. ... Cumulative or Continuous Trauma.

Key Takeaways. Workers' compensation is a form of employer insurance coverage that pays benefits to workers who are injured or become disabled as a result of their job. By accepting workers' compensation benefits, the employee waives the right to sue their employer for damages.

However, there are exclusions to this rule for some employers listed below: Any public employer including cities, counties, state agencies and state universities. Building and construction contractors for public employers. Motor bus companies and motor carriers.

Under section 39, entitlement to weekly payments is available for a maximum (aggregate) period of 260 weeks (five years). This applies unless a worker has been assessed as having a permanent impairment of more than 20 per cent.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232