Workers Compensation: GBGD-R

Workers' Compensation Insurance protects all employees in the event of an injury arising out of and in the course of employment. The procedures outlined in this document shall be followed throughout the course of a workers’ compensation injury.

How To Report An Injury:

1) Emergency: Employees with an on-the-job injury needing immediate, emergency treatment should report to the Platte Valley Medical Center Emergency Room or the closest emergency care facility. Following emergency care, the employee shall report the accident to their immediate supervisor and complete the District accident report form. The supervisor shall sign and submit the completed form to the Office for Human Resources within four (4) days of the occurrence. The accident report form shall include full detailed information relating to the accident.

Emergency Medical Care: Platte Valley Medical Center 1600 Prairie Center Parkway Brighton, CO 8060l Phone: 303-498-1600

2) Non-Emergency: Employees injured on the job, but not needing emergency care shall report the accident to their immediate supervisor. A decision on the need for doctor's care will be made and an appointment scheduled if necessary. An accident report form shall be provided to the Office for Human Resources within four (4) days of the occurrence. Failure to complete the accident form within this time period may result in the forfeiture of part or all of the benefits to which an employee would otherwise be entitled.

3) Designated Services: Medical Services: 27J has designated the following physicians and care facilities for work related injuries: Injury Care Colorado, Premier Occupational Medicine and Occupational Medicine located at 9351 Grant Street, Suite 600, Thornton, CO 80229 Phone:720-531-8377 or Colorado Occupational Medical Partners located at 9025 Grant Street, Suite #200, Thornton, CO 80229 Phone: 303-292-0034. The employee must use Designated Services listed above. Medical costs for services received outside these designees or their direct referrals will not be covered under Workers' Compensation and are the responsibility of the employee.

In the event an employee receives medical attention from any of the aforementioned physicians or care facilities, the employee will be permitted to return to work if the doctor unconditionally releases the employee. In the event the employee is released with restrictions, a decision will be made by the principal/supervisor with the Office for Human Resources Administrator as to whether or not the employee may safely and productively return to work.

4) Benefits: The School District is self-insured for purposes of Workers’ Compensation through Rocky Mountain Risk Insurance Group a self insurance pool comprised of three Adams County School Districts.

The administrator of the District's Workers’ Compensation Program is: CCMSI, P. O. Box 4998 Greenwood Village, CO 80155 Phone: 303-804-2032 Fax: 217-444-2709. If an employee is injured on the job, he/she should give the above information to the doctor, clinic or hospital and have bills sent directly to the administrator. This will eliminate any unnecessary paper work in a claim. The administrator, when liability is assumed, pays in accordance with the Industrial Commission.

Payment: All reasonable and necessary medical expenses will be paid directly to the doctor, clinic or hospital. An employee who suffers a work related injury and who is eligible to receive Workers’ Compensation disability payments shall continue to receive his/her regular salary and benefits for a period of thirty (30) work days following the date of the injury. After thirty (30) work days, the employee is entitled to two-thirds (2/3) of his/her average salary, subject to the maximum set by the State Industrial Commission, paid by our Workers' Compensation Program. Compensation is paid every two weeks, based on a seven-day week.

Death Benefits: In the case of death, as a direct result of an individual accident, benefits will be paid to eligible recipients in accordance with law.

Limitations: Compensation can be reduced by 50% for failure to follow safety rules, failure to utilize safety devices, or for use of alcohol or controlled substances.

Receipt and instructions acknowledge this ______ day of _______________________,________

EMPLOYEE SIGNATURE_______________________________________________ _______________

PLEASE KEEP ONE COPY

Revised: October 24, 2023