Verification of Employment for a Workplace Injury or Illness
Injured employees should take the completed form with them on their first healthcare provider visit.
Injured employees should take the completed form with them on their first healthcare provider visit. The form describes the workplace injury and includes contact information for billing and submitting work status reports.
You'll need to log in to keep reading.
This information is exclusively for members with Workers' Compensation access.
Log in Request AccessOther Resources You May Also Like...
Bona Fide Offer of Employment Template
When the doctor clears your injured employee to return to work, use this template to issue a bona fide offer of employment that meets state requirements.
Employee Acknowledgement of Alliance Direct Contracting Program
Employees must sign this form acknowledging they understand how to receive health care in the Political Subdivision Workers’ Compensation Alliance. Available in English and Spanish.