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Loss Occurrence Forms

Injury, Illness or Exposure *Required*

Injury/Illness Occurrence Initial Reporting Form *Required*
Complete this form for all injury/illness or exposure occurrences, regardless of how minor they may seem. Instructions for completing and reporting of all WC paperwork is located toward the bottom of this form.

Medical Waiver & Consent Form *Required*
Have the involved employee complete this form and fax it to HRRM at 270-901-3162.

Injury, Illness or Exposure Supplemental Documents

Physician's Return to Work Statement
The employee must present this document to the treating physician during any visit involving a work related injury/illness. The completed form must be returned to the employer as soon as practical following the visit.

Company Nurse Information Card
Company nurse supervisor card.

Prescription First Fill Card
The purpose of the Prescription First Fill Card is to provide the involved employee with a means for obtaining the first prescription without requiring an out-of-pocket cost. The card may only be used for the first prescription and may be used at only designated locations (listed on the card). When practical, the involved employee’s Supervisor or designated administrator should provide the employee with a copy of the card prior to the employee leaving to seek initial treatment

Waiver of Workers’ Compensation TTD Benefits Form

An employee who will be missing 1 or more days of work due to a work related injury/illness and wishes to receive their regular rate of pay in lieu of the workers’ compensation temporary total disability compensation must sign this form and return it to Safety/Risk Management.

Form 105 – Medical History
Have the injured employee complete this form if the injury or illness will require 7 or more days of “Lost Time”, surgery or the injured employee has previously experienced similar medical issues of that being reported. Please provide completed form to Safety/Risk Management as soon as possible.

Workers’ Compensation Questionnaire
Have the injured employee complete this form if the injury or illness will require 7 or more days of “Lost Time”, surgery or the injured employee has previously experienced similar medical issues of that being reported. Please provide completed form to Safety/Risk Management as soon as possible.

Auto Related Liability/Auto Physical Damage

Auto Loss Occurrence Form
Use this form whenever a City vehicle is damaged or involved in an accident involving a third part.

Property Damage

City Property Loss Occurrence Form
Use this form when reporting a City property loss.

General Liability (3rd Party Loss) Category

General Liability Injury Loss Occurrence Form
Use this form when a 3rd party is injured or allegedly injured on City property or is injured or allegedly injured from actions performed by the City.

General Liability - Property Damage Occurrence Reporting Form
Use this form when a 3rd party is alleging property damage as a result of actions performed by the City.

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