Policyholder Forms and Documents

The following documents and forms are available in both Microsoft Word file format (.doc) and in Adobe Acrobat portable document format (.pdf). Some are available in both English and Spanish languages, as indicated.


Table of Contents:

Audit Dispute Form
Building a Safety Plan
Compliance Poster
Distracted Driving
Drug-Free Workplace
Fraud Reporting
Injury Reporting
OMNET
Payroll Reporting Instructions
Policyholder Kit
Return to Work
Second Injury Fund

Audit

Audit Dispute Form (.pdf)


Building a Safety Plan

Building a Small Business Operational Safety Plan Booklet (.pdf)


Compliance Poster

Notice of Compliance Poster (English) (.pdf)
Notice of Compliance Poster (Spanish) (.pdf)


Distracted Driving

Distracted Driving Brochure (.pdf)
Distracted Driving Company Policy Sample (.doc)
Distracted Driving Employee Pledge (.doc)


Drug-Free Workplace

Sample Drug-Free Workplace Policy Documents (English):

Example Supervisor’s Investigation Guide (.doc)
Example Supervisor’s Investigation Guide (.pdf)

Example Workplace Policy without Testing (.doc)
Example Workplace Policy without Testing (.pdf)

Example Workplace Policy with Testing (.doc)
Example Workplace Policy with Testing (.pdf)

Example Workplace Drug Testing Policy Letter to Employees (.doc)
Example Workplace Drug Testing Policy Letter to Employees (.pdf)

Example Workplace Substance Abuse Policy Agreement (.doc)
Example Workplace Substance Abuse Policy Agreement (.pdf)

Example Informed Consent Agreement to Request Biological Specimen (.doc)
Example Informed Consent Agreement to Request Biological Specimen (.pdf)

Sample Drug-Free Workplace Policy (.pdf)


Sample Drug-Free Workplace Policy Documents (Spanish):

Ejemplo de una Guía de Investigación de un Supervisor (.doc)
Ejemplo de una Guía de Investigación de un Supervisor (.pdf)

Ejemplo de una Póliza Sobre Drogas y Alcohol en el Lugar de Trabajo sin Effectuar una Prueba (.doc)
Ejemplo de una Póliza Sobre Drogas y Alcohol en el Lugar de Trabajo sin Effectuar una Prueba (.pdf)

Ejemplo de una Póliza Sobre las Drogas y el Alcohol en el Lugar de Trabajo con un Prueba (.doc)
Ejemplo de una Póliza Sobre las Drogas y el Alcohol en el Lugar de Trabajo con un Prueba (.pdf)

Ejemplo de una Carta al Empleado y a su Familia (.doc)
Ejemplo de una Carta al Empleado y a su Familia (.pdf)

Ejemplo de Certificado de Acuerdo (.doc)
Ejemplo de Certificado de Acuerdo (.pdf)

Ejemplo de un Acuerdo de un Consentimiento Informado para Pedir un Espécimen Biologico (.doc)
Ejemplo de un Acuerdo de un Consentimiento Informado para Pedir un Espécimen Biologico (.pdf)

Ejemplo de Política de Lugar de Trabajo Libre de Drogas (.pdf)


Fraud Reporting

Fraud Reporting Kit (.pdf)


Injury Reporting

State Claims: Employer First Report of Injury or Illness (LWC-WC IA-1) (.pdf)
Longshore Claims: Employer’s First Report of Injury or Occupational Illness (USDOL LS-202) (.pdf)


OMNET

OMNET Managing Care Physician Statewide Directory (.pdf)
OMNET Medical Provider Search


Payroll Reporting Instructions

Payroll Reporting Instructions (.pdf)


Policyholder Kit

Certificates of Insurance (.pdf)
Claims Management (.pdf)
Claims Value-Added Services (.pdf)
Fraud Reporting (.pdf)
Legal Services (.pdf)
Longshore and Maritime Guide (2017–2018) (.pdf)
LWCC at a Glance (.pdf)
Medicare Secondary Payer Mandatory Reporting (.pdf)
Premium Audit (.pdf)
Reporting Purposes Only (.pdf)
Safety Services (.pdf)


Return to Work

Sample Return-to-Work Documents (English):

Sample Company Return-to-Work Policy (.doc)
Sample Employee Job Description (.doc)
Sample Physician Return-to-Work Letter (.doc)
Sample Post-Injury Return-to-Work Checklist (.doc)
Sample Transitional Duty Offer (.doc)
Sample Transitional Duty Offer Letter (.doc)


Sample Return-to-Work Documents (Spanish):

Sample Company Return-to-Work Policy (.doc)
Sample Employee Job Description (.doc)
Sample Physician Return-to-Work Letter (.doc)
Sample Post-Injury Return-to-Work Checklist (.doc)
Sample Transitional Duty Offer (.doc)
Sample Transitional Duty Offer Letter (.doc)


Second Injury Fund

Second Injury Fund Medical History Questionnaire (English) (.pdf)
Second Injury Fund Medical History Questionnaire (Spanish) (.pdf)