Sedgwick Kroger Claims Phone Number – 2 Dear Policyholder: We welcome you as a policyholder of Dallas National Insurance Company. Sedgwick is your claims administrator and we are pleased to be able to provide you with workers’ compensation claims processing services. Please follow the instructions below to file a new claim and note the claim kit attachment. Sedgwick Claims Kit Attachments Workers’ Compensation Notice and Instructions to Employers and Employees (Form 1A-English) Workers’ Compensation Notice and Instructions to Employers and Employees (Form 1A-English) Spanish) Employer’s First Report of Injury Form (Form 2) Employee’s First Notice of Injury Injury and Claim (Form 3) Workers’ Compensation Employee Frequently Asked Questions Claims Office Directory Medical Provider Finder Tool Employment Assistance First Fill General Atlas Temporary Pharmacy Card Atlas General Pharmacy Card Injury Report Nurse Advice Poster To Report a Claim Telephone: (855)-7ATLAS7) atlasgeneralinsurance@sedgwickcms. com Fax: Questions Linda Pettitt Customer Service Associate Direct: Loss Runs email@example.com Medical Provider Search Username: firstname.lastname@example.org Login Password: SedgwickCMS_123 (case sensitive) We appreciate your trust and believe that communication is essential to successful claims management. We encourage you to contact us if you have any questions.
3 Form 1A Oklahoma Workers’ Compensation Notice and Instructions to Employers and Employees All employees of this employer who are entitled to the benefits of the Workers’ Compensation Code are hereby notified that this employer has complied with all rules of the Workers’ Compensation Court and that the Employer has obtained payment of compensation to all employees and their dependents in accordance with the Code. All employees are further advised that this employer will provide first aid, medical, diagnostic, surgical and any other similar services required by law and compensation to any injured employee as provided in the Workers’ Compensation Code . Any employee who has suffered a compensable injury covered by the Workers’ Compensation Code is entitled to vocational rehabilitation services, including retraining and job placement, if, because of the injury, the employee is unable to perform the same professional tasks that the employee. was playing before the injury. The Oklahoma Workers’ Compensation Court has a counselor (ombudsman) program to provide information to injured workers, employers and other interested parties. Mediation is available to resolve some workers’ compensation disputes. For more information, call or call toll-free in the state Employer’s signature Insurer and insurer’s telephone number Employee responsibilities in the event of a workplace accident In the event of accidental or impact injury on cumulative trauma or occupational illness arising from and during employment, however slight, the employee must immediately inform the employer. If this employer is a partnership, notice must be given to any partner. If such employer is a corporation, notice must be given to any agent or officer of the corporation upon whom legal process may be served. Notice must also be given to the person in charge of affairs at the place of operations where the injury occurred. Unless notice is given to the employer or medical treatment is provided within thirty (30) days following the injury, any claim for compensation may be permanently barred. If accidentally injured or affected by cumulative trauma or occupational illness, the employee can file a claim for compensation in workers’ compensation court. Forms for filing a compensation claim must be provided by that employer and are also available from the Workers’ Compensation Court. The forms are posted on the Court’s website. A request for compensation must be filed with the Court within the time limit provided by law, under penalty of definitive limitation. Pursuant to the law in force on August 26, 2011, a claim for compensation for any accidental injury or death must be filed with the court within two (2) years from the date of the accidental injury or death ; a claim for compensation for occupational disease must be filed within two (2) years following either the last dangerous exposure or from the date on which the disease first manifested itself, whichever is later. ‘is produced; and a claim for cumulative trauma compensation must be filed within two (2) years of the employee’s last employment with the employer. However, claims may be filed within two (2) years from the date of the last medical treatment authorized by the employer or payment of any compensation or remuneration paid in lieu of compensation. Any person receiving temporary disability benefits from an employer or the employer’s insurance company must, within seven (7) days, notify the employer or insurance company in writing of any changes in a material fact or the amount of income that the employee receives or any change in the professional situation of the employee, occurring during the period of receipt of these benefits. Responsibilities of the Employer The employer must provide employees with immediate first aid, medical, diagnostic, surgical and any other similar services that are reasonable and necessary. This applies to care for all injuries and illnesses arising from and in the course of work, regardless of their nature. If an employee is injured and it results in lost time beyond their shift or requires medical attention away from the workplace (fatal or otherwise), the employer MUST file a Form 2 with the Court of workplace accidents in ten (10). ) days following notification of injury. The employer must provide a copy of Form 2 to its workers’ compensation insurance company, if applicable. No agreement by an employee to pay any portion of the premiums paid by the employer to maintain or maintain indemnity insurance as required by law shall be valid. Any employer who deducts money from the wages of an employee for this purpose who is entitled to workers’ compensation will be guilty of a misdemeanor. If the employer is actually notified of an uncontested injury and the employer’s insurance company does not begin paying the weekly temporary total disability benefits due within the time period provided by law, the insurer will pay to the employee a penalty of fifteen percent (15%) of weekly benefits not paid or delayed. No agreement by an employee to waive workers’ compensation rights and benefits shall be valid. Any person who commits workers’ compensation fraud, upon conviction, will be guilty of a felony. Workers’ Compensation Court 1915 North Stiles Avenue Oklahoma City, Oklahoma Tele (OKC) (TU) Free Statewide Website 08/11 This notice must be posted and maintained by the employer in one or more conspicuous places.
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4 Notification of Compensation for Workers of Oklahoma and Instructions for Employers and Employers Form 1A Hereby notifies all employees of this employer entitled to the benefits of the Compensation Code for Workers, which the mentioned employer has completed with all the standards of the Tribunal de Compensación de los Trabajadores and which guaranteed the payment of compensation for all employees and people in their cargo, according to the Code. In addition, you will notify all employees that this employer will provide first aid, diagnostic, medical, surgical and any other similar services required by law as well as compensation payments to any employee who sustains injuries in accordance with the law. to the Code. of Compensation for Workers. Any employee who has suffered a compensable injury covered by the Workers’ Compensation Code will be entitled to vocational rehabilitation services, including rehabilitation and work placement if, as a result of the injury, the employee cannot assume certain of its obligations. laborales which desempeñaba before producing the lesion. The Oklahoma Workers’ Compensation Court has an attorney (people’s advocate) program to provide information to injured workers, employers, and other interested parties. Mediation is available to handle certain controversies that concern workers’ compensation. Firma del Empleador Compañía Aseguradora y Número Telefónico de la Company For information, call or call toll-free within the state of the employee’s responsibilities in the event of work-related injuries. In the event that the employee suffers accidental injuries or resulting from accumulated trauma If a professional activity is carried out by the employer or in the course of employment, for many levels, the employer must be immediately informed of the ’employer. If the employer is a partnership, he must inform any sociologist. If the employer is a limited company, he must inform any representative or official of the company carrying out the legal activities. In addition, you must inform the person responsible for the business at the place of business operations where it occurs the injury. Salvo who notifies himself to the employer or carries out the medical treatment during the three (30) days of production of the injury, which will request compensation forever. In the event that the employee suffers injuries that are accidental or result from accumulated trauma or occupational disease, he or she can make a claim for compensation to the Workers’ Compensation Tribunal. The forms for submitting a claim for compensation must be
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