Initial coordinator actions

Collect and review initial documentation

When you receive notification of an employee injury, illness, or occupational exposure, you will need to obtain and review three forms:

1. Employee's Work Injury And Illness Form pdf — from the injured worker
2. Employer's First Report of Injury or Disease pdf — from supervisor or worker’s compensation coordinator
3. Supervisor's Accident Analysis and Evaluation of Repetitive Motion and/or Material Handling Activities pdf  — from supervisor

Prioritize claim and process accordingly

Prioritize claims as follows:

1. Fatality or multiple hospitalizations. URGENT, 8-12 hours.

• • See Fatality or multiple hospitalizations page for mandatory requirements.
  • Enter claims data into the Enterprise database. Fill in mandatory and required data fields per recommendations. See the Enterprise data entry resources page for more detail.
  • Fax completed forms immediately to the Worker’s Compensation Claims Examiners at UW System Administration: (608) 263-7330.
  • Continue with File documents and acknowledge receipt of claim, below.

2. Lost time. IMPORTANT, within 48 hours.

• • Enter claims data into the Enterprise database. Fill in mandatory and required data fields per recommendations in the STARS Web User Guide. See the Enterprise data entry resources page for more detail.
  • Fax completed three initial forms (above), plus any additional documentation, to Worker’s Compensation at UWSA: (608) 263-7330.
  • Continue with File documents and acknowledge receipt of claim, below.

3. Treatment by medical professional. No later than 14 days.

• • Enter claims data into the Enterprise database. Fill in mandatory and required data fields per recommendations in the STARS Web User Guide. See the Enterprise data entry resources page for more detail.
  • Continue with File documents and acknowledge receipt of claim, below.
  • If claim turns into a Lost Time claim, immediately fax documentation pertaining to the Lost Time to Worker’s Compensation at UWSA: (608) 263-7330.

4. Incident (no treatment by medical professional). No later than 14 days.

• • Enter claims data into the Enterprise database. Fill in mandatory and required data fields per recommendations in the STARS Web User Guide. See the Enterprise data entry resources page for more detail.
  • Continue with File documents and acknowledge receipt of claim, below.

File documents and acknowledge receipt of claim

• Send original claim documents to the Claims Examiner at UW System Administration, a copy to your Safety Manager, and keep a copy in your files. This must be done within 14 days of the report of injury/illness.
• Send receipt of claim acknowledgement to the injured worker and to his/her department.

Fatalities & Multiple Hospitalizations

Time-sensitive reporting requirements

Your campus has an obligation to notify State occupational health and safety regulators about the death of any UW System employee from a work-related incident within eight (8) hours of its occurrence.

• During normal business hours, contact the Department of Safety and Professional Services at 608-267-9420.
• During non-business hours, contact Wisconsin Emergency Management at 800-943-0003.

Worker’s compensation coordinators should verify in advance who is responsible for their campus notification in these situations.

All employee deaths must be reported to a Claims Examiner at UW System Administration within 12 hours since the Claims Examiner has 24 hours to report to DWD and DOA.

Other

Process claim information (including WKC-12) and submit to the Claims Examiner. Assist in investigation by obtaining facts of injury and resulting death. Provide next of kin/contact person, list of dependents, police report and death certificate when available.

Work-related fatalities are OSHA recordable. On the OSHA tab, select OSHA Recordable, the appropriate injury/illness category, and severity 5 for Death.