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Incident Report Form: Workers’ Compensation:
Workers’ Compensation insurance (WC) provides benefits to University employees who suffer work-related injuries or illnesses arising out of and during the course and scope of employment, whether on University locations or off premises. These benefits include payment for medical treatment, prescriptions, and other expenses related to the injury or illness. Benefits may also include payment for lost time from work due to the injury or illness, depending on the number of days the employee is out of work.
The University’s Maine based employees are self-insured for worker’s compensation insurance through a State of Maine approved program. The program is administered by Cannon Cochran Management Services Inc (CCMSI), a third party administrator, with administrative oversight by the System’s Risk Manager. Each campus has designated a Workers’ Compensation Administrator to manage campus workers’ compensation claims. The workers’ compensation contacts can be found in Section II below.
For employees outside Maine, WC coverage is provided by policy or other State approved programs. Please contact HR for claims.
Systemwide Contacts for Workers’ Compensation
Cannon Cochran Management Services Inc. (CCMSI)
Sara Barger Grant – Lost Time Claims
Rebecca Elliott – Medical Only Claims
Malissa Howe – Supervisor
Adam Green, Risk Manager
UMS, 16 Central Street, Bangor, ME 04401
Campus Workers’ Compensation Administrators
|University of Maine||Catherine Degrasse||(207) email@example.com|
|University of Maine at AugustaUniversity College of BangorUniversity College Centers||Lorraine Theriault||(207) firstname.lastname@example.org|
|University of Maine at Farmington||Rick Tyler||(207) email@example.com|
|University of Maine at Fort Kent||Dori Pratt||(207)firstname.lastname@example.org|
|University of Maineat Machias||Kim Page||(207) email@example.com|
|University of Maine at Presque Isle||Dori Pratt||(207)firstname.lastname@example.org|
|University of Southern Maine||Claire Hassler||(207) email@example.com|
|System Office (all locations)||Adam Green||(207) firstname.lastname@example.org|
A. First steps if an Injury Occurs
A University employee’s health and safety should be the primary concern at all times. When an incident occurs, it is important to follow the best course of action given the circumstances. Below are some general guidelines, or first steps, in the event of an incident that causes or almost causes a work injury.
Emergencies: Call 911 whenever appropriate and necessary. If the injury requires immediate emergency medical attention, the employee should go to the nearest Emergency Care facility, utilizing an ambulance service when needed or requested. For an overnight admission to a hospital or if there is a fatality, immediately notify appropriate campus administration.
Non-Emergencies: Minor injuries requiring first-aid only may be treated on-site. However, the campus or System workers’ compensation administrator may make the determination that the injured employee needs to see a medical provider; if such a determination is made, the employee must see the University’s preferred medical provider.
University’s Preferred Medical Providers
University of Maine
Cutler Health Center (207) 581-4179
Long Road, University of Maine
University of Maine at Augusta
Workplace Health (207) 626-7250
10 Caldwell Road, Augusta, ME 04330
University College of Bangor
Workwell (207) 907-3010
900 Broadway, Bangor, ME 04407
University of Maine at Farmington
Franklin Memorial Hospital (207) 779-2367
111 Franklin Memorial Drive, Farmington, ME 04938
University of Maine at Fort Kent
NMMC – Northern Maine Medical Center (207) 834-3155
194 East Main Street, Fort Kent, ME 04743
University of Maine at Machias
Arnold Medical Center (207) 497-5614
70 Snare Creek Land, Jonesport, ME 04649
University of Maine at Presque Isle
Aroostook Medical Center (207) 768-4000
140 Academy Street, Presque Isle, ME 04769
University of Southern Maine
Concentra (207) 774-7751
85 Western Ave, Portland, ME 04106
System Office (Bangor)
Workwell (207) 907-3010
900 Broadway, Bangor, ME 04407
Important Notes: All injuries, whether covered by workers’ compensation or not, must be reported to the employee’s supervisor and designated campus staff. The System-wide incident reporting guidelines found in this document are in addition to any local campus-developed guidelines related to injuries, illnesses and incident reporting. Also, any person who knowingly makes false claims or statements, or conceals any material fact in order to receive workers’ compensation benefits, may be subject to criminal penalties including jail.
1. Notify Supervisor: An employee who is injured at work must notify their supervisor immediately (within 24 hours) of the injury. In addition, the employee must also report incidents that almost caused an injury, in order to assist the University to possibly avoid a future injury.
2. Complete Incident Report Form: With the employee’s assistance, the supervisor needs to complete the workers’ compensation incident report form: Workers’ Compensation: Employee Injuries & Illnesses and submit it to the campus workers’ compensation administrator (or, at the UM campus, the supervisor reports the incident directly to CCMSI on-line). The Campus WC Administrator is also available to assist the employee or supervisor in completing the form.
3. Notify Campus WC Administrator
At all campuses except the University of Maine, once the incident report form has been completed, provide the form or information to the Campus WC Administrator (see section II). At the University of Maine, the employee’s supervisor (UM Supervisor) will report the claim directly using the CCMSI on-line reporting system.
4. Reportable Claims (Notification to State and Third Party Administrator)
The Campus WC Administrator (or UM Supervisor) will notify CCMSI by completing a report through the CCMSI on-line reporting system or faxing in a completed incident report form (see section V). If there are any questions regarding reporting, contact the on-site Claims Representative, Loree Libby (207-262-4386; or toll free: (866) 787-8894; or email: LLibby@ccmsi.com).
5. Non-Reportable Claim
If an injury does not require medical treatment or the treatment is first-aid only and no time was lost from work, then the incident does not need to be reported to the State; however, the employee should still notify his or her supervisor and appropriate campus administration regarding the injury, and the incident should still be reported to CCMSI via the on-line reporting system as a report only.
C. The Claim Process
1. The Claims Representative will contact the employee within 24-48 hours of the injury to discuss the claim and explain the workers’ compensation claim process and benefits. The employee will also be mailed a “Release of Medical/Health Care Information Form,” a “Statement of Injured Employee Form,” a “Mileage Reimbursement Request Form” and, when applicable, a prescription card. The “Release” and “Statement” forms are required to receive WC benefits and must be completed, signed and returned to the Claims Representative. The “Mileage Reimbursement Request Form” is for reimbursement of covered travel; the employee’s mileage to and from medical provider’s appointments is covered as a benefit at a rate determined by the State. The prescription card is for any medications prescribed as a result of the injury. See Section V below for relevant forms.
2. The Claims Representative will also contact the employee’s supervisor to gather additional information on the incident and inform the supervisor of the claim process.
3. If the employee is unable to work due to the injury, the Claims Representative will monitor the situation and work together with the supervisor to have the employee return expeditiously to his or her position, if possible. It is the University’s goal to help injured employees return to work as soon as they are ready and able, as determined by the medical provider and Claims Representative. If the employee is released by their medical provider to return to work with restrictions, the employee should provide that notice to his or her supervisor. If the University can accommodate the restrictions, the employee is obligated under the Maine Workers’ Compensation Act to return to work
D. Funding Claims
An employee’s lost time pay is funded by the injured employee’s department or campus (unless the claim is determined by the System to be a lifetime claim). Settlements, medical, legal and other expenses are funded by the System benefits pool administered by the System Office (the pool is funded by the campuses through an employee fringe benefit percentage assessed against salary and wages).
IV. Forms and Links
Letter regarding Workers’ Compensation Coverage for University of Maine System Employees
Non Maine Workers’ Compensation: Injuries & Illnesses
Release of Medical/Health Care Information Form
Statement of Injured Employee Form
University of Maine Employee Accident Reporting: http://www2.umaine.edu/SEM/accident.htm
University of Southern Maine Employee Accident Reporting: http://www.usm.maine.edu/hrs/benefits/
For more information on Maine Worker’s Comp Benefits, please refer to the link below:
Maine Workers’ Compensation Board: http://www.maine.gov/wcb/index.html
Maine Workers’ Compensation Law: http://janus.state.me.us/legis/statutes/39-A/title39-Ach0sec0.html
Maine Workers’ Compensation Board Publications: http://www.maine.gov/wcb/publications.html