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Forms & Brochures

WORKPLACE WORKERS’ COMPENSATION NOTICES (POSTERS)

The workplace workers’ compensation notices (posters) required by statute are NOT subject to OIC review or approval

West Virginia Code § 23-2C-15(c) requires, in part, that:

  “Every employer shall post a notice upon its premises in a conspicuous place identifying its workers' compensation insurer. The notice must include the name, business address and telephone number of the insurer and of the person to contact with questions about a claim. The employer shall at all times maintain the notice provided for the information of his or her employees.”


There is currently no legislative rule addressing this requirement, and the workplace notices required by § 23-2C-15(c) are not subject to review or approval by the OIC. However, OIC interprets this statute as requiring two basic pieces of information to be set forth in the notice.

First, the statute simply requires that the notice include the name, business address and telephone number of the employer’s workers’ compensation insurer. This requirement is straightforward and self-explanatory.

Second, the statute requires that the notice should contain information regarding the “person” an injured worker may contact with any questions he or she may have regarding a claim. OIC interprets this requirement broadly. The “person” identified in the notice may be 1) an employee of the injured worker’s employer – for example, a manager, human resources director or employee benefits coordinator; 2) an adjuster for the insurer; or 3) the insurer’s third-party claims administrator. However, the “person” identified: 1) should be readily available to the injured worker to personally assist the injured worker with the injured worker’s claim; and 2) should possess sufficient knowledge about the workers’ compensation claims process to adequately do so.

With regard to the physical composition of the notice, the statute provides no requirements with regard to the composition or size of the notice, or typeface used in the notice, and these determinations are left to the discretion of the insurer. It should be noted that the statute requires the notice to be posted in a conspicuous place upon the employer’s premises. Consistent with spirit of this directive, notices should be composed in a fashion that will provide workers with the required information in a legible format that can be easily seen and understood.

BROCHURES

       


The following brochures have been prepared by the OIC for use in claims made against State-administered workers’ compensation claims. The purpose of these brochures is to outline the claims process and the benefits available to injured workers. Brochures that are based on the form used in these OIC brochures are deemed to be approved; private carriers may prepare brochures utilizing their own trade dress, and should modify their brochures as necessary to provide the claimant with accurate contact information and other carrier-specific information.

For example, claimants in OIC-administered claims may choose any physician so long as that physician accepts payment from the OIC-administered funds, whereas there may be limitations regarding the choice of a physician under the managed care organization of a private carrier. Under these circumstances, the brochure used by the private carrier should be modified to reflect information regarding the private carrier’s managed care organization, how a physician is to be selected under that organization, and specific contact information where a claimant may obtain answers to any questions they may have.

      Claimants' Information Brochure - Sedgwick    
      Claimants' Information Brochure - American Mining    
      Claimants' Information Brochure - Wells Fargo    
                 
        The following brochures are additional brochures relating to workers’ compensation in West Virginia:
                 
    Adobe Acrobat Document   How to File an Insurance Complaint      
    Adobe Acrobat Document   Office Of Judges      
                 
WORKERS' COMPENSATION FORMS
                 
       

The following forms are approved for use in West Virginia workers’ compensation claims.
Private carriers may modify these forms with regard to trade dress and carrier-specific
Information (e.g., the name and mailing address of the private carrier or third party
administrator), and may alter the forms to provide space for the entry of information on the
form by the private carrier; HOWEVER, private carriers may NOT modify, add or subtract fields requesting information to be provided by injured workers without prior OIC approval.

These forms have recently been prepared by the OIC as examples of approved forms for general use:

                 
      Employees' and Physicians' Report of Occupational Injury or Disease [OIC-WC-1]      
      Employers' Report of Occupational Injury or Disease [OIC-WC-2]      
      Employee's & Physicians' Report of Occupational Hearing Loss [OIC-WC-1HL]      
      Application for Fatal Dependents' Benefits [OIC-WC-201]      
      Application for 104 Weeks Dependents' Benefits [OIC-WC-202]      
      Employees' Report of Occupational Pneumoconiosis [OIC-WC-10P]      
                 
        The following forms are currently in use by a third-party administrator of OIC-administered claims, and provide an example of additional forms which are approved for use in West Virginia:
                 
    Adobe Acrobat Document   Settlement Application      
    Adobe Acrobat Document   Application for Fatal Dependents’ Benefits      
    Adobe Acrobat Document   Application for 104 Weeks Dependents’ Benefits      
    Adobe Acrobat Document   Application for PTD Benefits      
    Adobe Acrobat Document   Controlled Substances Form      
    Adobe Acrobat Document   Attending Physician Benefits Form      
    Adobe Acrobat Document   Diagnosis Update      
    Adobe Acrobat Document   Direct Deposit Form 1-30-08      
    Adobe Acrobat Document   Employee and Physician’s Report of Occupational Hearing Loss      
    Adobe Acrobat Document   Employer’s Report of Occupational Disease      
    Adobe Acrobat Document   Employer’s Report of Occupational Pneumoconiosis      
    Adobe Acrobat Document   Hearing Loss Exposure Addendum      
    Adobe Acrobat Document   Low Back Examination      
    Adobe Acrobat Document   Physician’s Report of OP      
    Adobe Acrobat Document   Request for Change or Opt-Out      
                 
        The following forms are additional forms related to workers’ compensation coverage in West Virginia:
                 
    Adobe Acrobat Document   Termination of Coverage Form    
    Adobe Acrobat Document   Workers' Compensation Complaint Form      
    Adobe Acrobat Document   Self-Insured Workers' Compensation Complaint Form    
 
 
Notices & Other Info
    Request for File Copies    
  Adobe Acrobat Document   Dispute Resolution Process      
    Workers' Compensation Benefits Rates FY2010      
  Adobe Acrobat Document   WV Workers' Compensation Assigned Risk Plan      
  Adobe Acrobat Document   Assigned Risk Plan Rates Effective January 1, 2009      
    NOTE: The 2009 WV Workers' Compensation Loss Costs will become effective on November 1, 2009. Updated loss costs will be published approximately 30 days prior to the effective date.  
  Adobe Acrobat Document   WV Workers' Compensation Loss Costs effective July 1, 2008      
  Adobe Acrobat Document   WV Workers' Compensation Loss Costs effective July 1, 2007      
  Adobe Acrobat Document   WV Workers' Compensation Loss Costs effective July 1, 2006      
  Adobe Acrobat Document   NCCI Payroll Definition      
  Adobe Acrobat Document   Uninsured Fund Application    
  Adobe Acrobat Document   Application for Exemption from WV Workers' Compensation Coverage    
  Adobe Acrobat Document   Notification for Claims Allocation      
  Adobe Acrobat Document   Carriers Request For Occupational Lung Center Examination    
  Adobe Acrobat Document   Travel Expense Notice      
  Adobe Acrobat Document   2009 OIC WV Workers Compensation Benefits Calendar    
  Adobe Acrobat Document   2008 OIC WV Workers Compensation Benefits Calendar    
  Adobe Acrobat Document   Workers' Compensation Carrier Forum September 2007 - Frequently Asked Questions Workers' Compensation Carrier Forum September 2007 - Frequently Asked Questions      
  Adobe Acrobat Document   West Virginia Workers' Compensation Market Transition Circular Workers' Compensation Carrier Forum September 2007 - Frequently Asked Questions      
  Adobe Acrobat Document   WV Workers' Compensation Adjuster Training Seminar - May 22, 2008     Workers' Compensation Carrier Forum September 2007 - Frequently Asked Questions  
  Adobe Acrobat Document   WV Deliberate Intent Memo Workers' Compensation Carrier Forum September 2007 - Frequently Asked Questions      
  Adobe Acrobat Document   WC Carrier Conference Presentation for April 8, 2008 Workers' Compensation Carrier Forum September 2007 - Frequently Asked Questions      
  Adobe Acrobat Document   April 8, 2008 Carrier Conference FAQ Workers' Compensation Carrier Forum September 2007 - Frequently Asked Questions      
 
The above documents require the Adobe Reader ® to open properly. Click here to follow a link to the Adobe Reader ® download page.
 
 
 
           
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Jane L. Cline - West Virginia Insurance Commissioner State Of West Virginia Home Page West Virginia Offices of the Insurance Commissioner