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Workers' Compensation Procedures

The procedures and forms below should be used when preparing and filing information regarding workplace injuries, illnesses, and incidents.

Supervisor's Checklist

Forms

The following forms are to be completed and submitted  to your agency Workers' Compensation Coordinator as soon as possible but no later than 24 hours after the incident. Please refer to the Supervisor's Checklist for more detailed information.

Note: When accessing Microsoft Word documents from your web browser, be sure to save a local copy to your computer or network drive before completing. Once completed, attach the document to an email or print it for sending. In most cases, Microsoft Word does not allow spell check within form fields so do your best and don't worry too much about spelling errors. With PDF forms, simply print the form, complete it by hand and route for distribution.


Further information about the workers' compensation process can be found in the Supervisor's Workers' Compensation Handbook (PDF).


Workers' Compensation Coordinator Resources

Handling non-SEMA4 workers

The following two forms are to be completed by agency Workers' Compensation Coordinators for reporting work related injuries or illnesses involving employees that are not enrolled in SEMA4. Please complete the following forms and submit to the Workers' Compensation Program along with all forms indicated above.

  • Non-SEMA4 Employee Details Form (Microsoft Word) 
    This form is only to be used by agency Workers' Compensation Coordinators to report injuries or illnesses reported by employees that do not have a SEMA4 employment record (e.g. agencies not using SEMA4, student workers, volunteers, etc.).
  • 26 Week Wage Information Form (PDF) 
    This form is only to be submitted by those organizations who do not have access to the SEMA4 system and who require the assistance of the Department of Administration to provide workers' compensation coverage. This form is used to document employee's earnings when earnings are irregular, difficult to determine, or consist of overtime, differential or other special pay in at least one-half of the work weeks in the 26 weeks preceding the date of injury. If the employee's work status has changed during the 26 week period (e.g., full-time to part-time, part-time to full-time, promotion, demotion or is a new hire) provide wages only since the date of the most recent work status change and note the type of change. For organizations that can file the First Report of Injury through the SEMA4 system, a 26 week earnings report will be generated automatically.


Questions or Need Further Assistance?

If you have questions or need assistance related to preparing and filing the forms to report a possible work related injury or illness, or need help with workers' compensation claims management issues, please contact John Sargent via e-mail or at 651-201-3031.