What to Do When an Accident Occurs

When an accident occurs, you should first assess the employee's condition. If immediate medical attention is required, please proceed in securing medical treatment and the forms can be completed once the employee is stable. If the employee's condition is stable, the following forms should be completed prior to the employee leaving your premises.

An Accident Investigation Report will need to be completed by the supervisor and the injured employee. This form was designed to assist in investigating the accident and to ensure that corrective action is taken so that similar accidents can be prevented. The employee will complete the top portion of this form and the supervisor will complete the bottom portion. Please make sure that all questions are answered in detail. It is important to document as much about the accident as possible prior to the employee leaving the premises.

If the Accident Investigation form indicates witnesses, each witness should complete a Witness Statement Form. This form should be completed in detail. We recommend that this form not be completed in the presence of the injured employee.

The next form is the Authorization for Disclosure of Medical Information. This form authorizes us to request and receive the injured employee's medical records. Though we are entitled to these records without this form, it is especially useful when a claim is denied or treatment was received without authorization.

The next form is the Medical Authorization for Treatment. This form should be provided to the injured employee prior to seeking medical treatment. You will be responsible for completing the top portion of the form and indicating where the employee is to seek treatment. If you do not have an authorized treating physician, please let your Claims Representative know. You should instruct the employee to return this form to you after receiving medical treatment. This form provides you with valuable information regarding the employee’s diagnosis, prognosis, and work status.

The final form is the First Report of Injury (North Carolina Industrial Commission Form 19). Once you complete the Form 19 and print the document, it will automatically be forwarded to your Claims Representative. Please retain a copy of the Form 19 for your records and a copy of both front and back must be provided to the employee. In addition to providing the Form 19 to the employee, you must also provide a blank Notice of Accident to Employer and Claim of Employee (North Carolina Industrial Commission Form 18) to the employee. Please refer the employee to instructions on the Form 19 for completion of this form.

The originals of the Accident Investigation Form, Witness Statement (if applicable), Authorization for Disclosure of Medical Information, and the Medical Authorization for Treatment should immediately be mailed or faxed to the attention of your Claims Representative.

Claims Representatives can be reached at (800) 658-1492. Our office is open Monday through Friday, 8:00 a.m. to 5:00 p.m. If you phone after hours, you should leave a message in voice mail and your call will be returned at the beginning of the next business day.

Once we have received all claims information, your assigned Claims Representative will contact the injured employee and any witnesses to discuss the accident and determine compensability. Please let your employee know to expect our call. We can not issue payment for any outstanding medical charges until we have determined coverage applies.

Your Claims Representative will maintain constant contact with you until the injured employee is released to be returned to work and is back to their pre-injury state.