Loss Occurrence Forms

Injury, Illness or Exposure

Company Nurse Information Card
Company nurse supervisor card.

Exposure Incident Detailed Report Form
Use this form to document the exposure incident in detail and to obtain reporting and treatment information. This form is used in addition to other injury/illness reporting forms.

Injury/Illness or Exposure Occurrence Initial Reporting Form
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
Have the involved employee complete this form and fax it to HRRM at 270-901-3162.

Notice of Designated Physician & Payment Obligor Information Form
Use this form for providing payment information (payment obligor) to the treating medical facility. The designated physician portion of this form is also to be completed when the employee has determined their primary physician.

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.

Prescription First Fill Card
Use this information to obtain the first fill of prescription medication for a WC injury/illness claim. If the pharmacy will not take the card, use you credit card and turn receipt into HR. DO NOT USE HEALTH INSURANCE TO PAY FOR WC RELATED ITEMS.

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 Loss Occurrence Form
Use this form when a 3rd party property is damaged or allegedly damaged as a result of operations performed by or on behalf of the City.



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