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
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
6. Prescription First Fill Card
7. Drug Screen Custody and Control Form (obtain from HR if applicable)
8. PATIENT AUTHORIZATION TO RELEASE INFORMATION
9. Timesheet Entry
10. State Specific Claim Form (find form below, only applicable if listed in the section)
11. I&O Medical Center Authorization Form

 

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

PLEASE CONTACT MANCON HUMAN RESOURCES AT 757-457-9333 FOR PHYSICIAN PANELS

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