Workers Compensation


Welcome to MANCON’s Workers Compensation Page. The following information and forms are provided as an initial response to an employee’s claim for a work-related injury, illness, or an incident that involves MANCON or non-MANCON auto, property or other damage.

Manager/Supervisor Instructions
1. WC Checklist Manager Supervisor
2. WC Instructions for Managers/Supervisors

Supervisor Completes the following
1. Incident Report Dec 2016
2. Medical Treatment Authorization
3. State Specific Form, see below if applicable

Provide the following to the employee when notified of an incident
1. Workers Comp instructions for employees
2. Physician Panel (find panel below based on the work location of the employee)
3. MANCON Panel
4. Medical Treatment Authorization
5. Physician Return to Work Form
6. Prescription First Fill Card
7. Drug Screen Custody and Control Form (obtain from HR if applicable)
8. Medical Release
9. Timesheet Entry
10. State Specific Claim Form (find form below, only applicable if listed in the section)

 

Other Forms
1. Witness Statement
2. Police Reports (if applicable)

State Specific Claim Forms
Alaska
Arizona
Arkansas
California
Kansas
Illinois
Maryland
Ohio 
Washington DC

Physician Panels
If the state is not listed below, MANCON cannot direct care, therefore employees in those states can seek treatment at any medical facility.

Alabama
No current sites
No sites at this time

Arizona

WW Phoenix
WW Tuscon VA Hospital

California

Afloat West San Diego
DMDC Seaside
NMC – San Diego
NWS Seal Beach
PSD Port Hueneme
PSD NAS Lemoore
PSD San Diego
San Diego Site Office
WW Camp Pendleton

Colorado

WW Colorado Springs
WW Fort Carson
Connecticut
PSD New London 
Delaware
WW Wilmington
Florida
City of Cape Coral
City of Tampa – North Clark
City of Tampa – Chestnut Street
Martin County Utilities Warehouse
Mayport Site Office
PSD Jacksonville
PSD Mayport
WW Jacksonville
WW Orlando
PSD Kings Bay
WW FORT BENNING
WW Fort Gordon
WW Fort Stewart
Idaho
 No current sites
Illinois
NAVAL STATION GREAT LAKES
PSD Great Lakes
Indiana
NACFAC Midwest Det Crane 
Iowa
No current sites
No current sites
Kentucky
WW Fort Campbell – Contact HR

Maryland

Massachusetts

Michigan

WW Detroit
City of Detroit
City of Detroit – Fire
City of Detroit – Street Maintenance
Minneapolis

Missouri

509 MDG-F4E41A Bain Walling
WW St. Louis
Mississippi
No current sites
Montana
No current sites
Nebraska

New Hampshire

 No current sites
New Mexico
  No current sites
Charlotte Douglas Airport
PSD Camp Lejeune
WW Fort Bragg
87 MED GROUP-F3A4S9
CSD NAS Fallon
No current sites
No sites at this time
Rhode Island
PSD Newport
628th Medical Group
NWS Charleston
South Dakota
 No current sites
No sites at this time
Texas
Corpus Christi Army Depot
Dallas Independent School District – Contact HR
El Paso – Contact HR
WW Fort Hood – Contact HR
WW Fort Sam Houston – Contact HR
WW For Bliss – Contact HR

Vermont
 No current sites
Virginia

ATAC Norfolk
CORPORATE
City of Harrisonburg
E2I HEADQUARTERS
FLC Norfolk
Hampton Rds Naval Museum
HAMPTON ROADS SITE OFFICE
MTF Langley AFB
PSD Norfolk
SERVMART
VDOT Abingdon
VDOT Accomac
VDOT Alexandria
VDOT Amelia
VDOT Ashland
VDOT Bassett
VDOT Bedford
VDOT Bristol
VDOT Charlottesville
VDOT Chatham
VDOT Christianburg
VDOT Colonial Heights
VDOT Courtland
VDOT Culpeper
VDOT Dillwyn
VDOT Fairfax
VDOT Fredericksburg
VDOT Halifax
VDOT Harrisonburg
VDOT Hillsville
VDOT Jonesville
VDOT Leesburg
VDOT Lynchburg
VDOT Manassas
VDOT Norfolk
VDOT Oakwood
VDOT Pine Chapel
VDOT Salem
VDOT Saluda
VDOT Sandston
VDOT South Hill
VDOT Staunton
VDOT Suffolk
VDOT Tazewell
VDOT Triangle
VDOT Warrenton
VDOT Warsaw
VDOT Winchester
VDOT Wise
VDOT Wytheville
WW Fort Belvoir

Washington DC
No sites at this time

West Virginia
No current sites

Wyoming

No current employees

Safety Training Materials for Managers/Supervisors
Safety Training Sign-In Sheet
Administrative Positions Safety Packet 2013
Driving Positions Safety Packet 2013
Maintenance and Machinery Positions Safety Packet 2013
Warehouse and Material Mover Safety Packet 2013