|
When an Incident Occurs – Massachusetts
The
following steps should be taken when a work related
injury/incident occurs. (Please note, in the event
of a catastrophic claim, contact Atlantic Charter
immediately at (617) 488-6500.)
-
Complete the Employee
Incident Report
This report should be completed jointly by the
employee’s supervisor and the injured
employee.
Section 1 documents general
information about the employee, when and where
the incident occurred, who was involved, what
treatment has occurred, and the current work
status.
Section 2 should ONLY
be completed by the injured employee. The employee
should write a detailed statement explaining
what occurred and what injury resulted. The
employee should then sign the statement where
it is indicated.
Section 3 is a medical
release which the employee should be asked to
sign. This release allows Atlantic Charter access
to medical information pertaining to the injury
which the employee is claiming.
Determine if the
incident will result in 5 or more calendar days
of incapacity
Incidents which require medical treatment but
result in less than 5 calendar days of incapacity
are considered “Medical Only” claims.
They should be reported to Atlantic Charter
via the Employee
Incident Report. Please include
any other supporting documentation. Notice to
the State/Department of Industrial Accidents
is not required.
For any injured employee
who is incapacitated for a period of 5 or more
calendar days from earning full wages, a Form
101 Employer’s First Report of Injury
or Fatality, must be filed within
7 calendar days, not including Sundays and holidays,
to the Department of Industrial Accidents, with
a copy sent to Atlantic Charter and the employee.
Please note that late reporting by the employer
may result in a fine being levied.
All forms including the
Employee Incident
Report, Supervisor
Investigative Report and First
Report of Injury must also be reported
to Atlantic Charter Insurance.
Please mail the
original or fax a copy to:
Atlantic Charter
Insurance Company
25 New Chardon Street
Boston, MA 02114
Attn: Claims Department
Fax (617) 488-6502
When
an Incident Occurs – New Hampshire
The
following steps should be taken when a work related
injury/incident occurs. (Please note, in the event
of a catastrophic claim, contact Atlantic Charter
immediately at (800) 364-6662.)
-
Complete the Employee
Incident Report
This report should be completed jointly by the
employee’s supervisor and the injured
employee.
Section 1 documents general
information about the employee, when and where
the incident occurred, who was involved, what
treatment has occurred, and the current work
status.
Section 2 should ONLY
be completed by the injured employee. The employee
should write a detailed statement explaining
what occurred and what injury resulted. The
employee should then sign the statement where
it is indicated.
Section 3 is a medical
release which the employee should be asked to
sign. This release allows Atlantic Charter access
to medical information pertaining to the injury
which the employee is alleging.
Complete the Employer’s
Report of Occupational Injury or Disease (8WC)
All claims, regardless of treatment, must be
reported to the State of New Hampshire Department
of Labor. The First Report must be filed as
soon as possible after knowledge of any occupational
injury or disease, but no later than five days
thereafter.
If the employee’s
incident resulted in four or more calendar days
of incapacity to earn full wages, then a Supplemental
Report Form (13 WCA) must also be filed with
the Department of Labor no later than seven
days after the date of injury. Please note that
late reporting may result in a fine being levied.
Please mail the
original forms or fax a copy to:
The State of New
Hampshire, Department of Labor
P.O. Box 2077
Concord, NH 03302-2077
Fax (603) 271-6149
- All forms including the
Employee Incident
Report, Supervisor
Investigative Report, First
Report of Injury and Supplemental
Report of Injury must also be reported
to Atlantic Charter Insurance.
Please mail the
original forms or fax a copy to:
Atlantic Charter
Insurance Company
25 New Chardon Street
Boston, MA 02114
Attn: Claims Department
Fax (617) 488-6502
Reporting
a Claim
Report an injury to
Atlantic Charter-
-
By FAXING
a completed First Report of Injury to (617)
488-6502
-
By INTERNET
at www.atlanticcharter.com (NH Only)
-
By MAILING
a completed form to us within 24 hours
- Atlantic Charter Insurance
Co.
- 25 New Chardon Street
- Boston, MA 02114
*All claims should
be reported to Atlantic Charter within 24 hours
of your notice or knowledge of an injury.
|
