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 for Supervisors
2. Workers Comp instructions for 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. Drug Screen Custody and Control Form (obtain from HR if applicable)
7. PATIENT AUTHORIZATION TO RELEASE INFORMATION
8. Timesheet Entry
9. State Specific Claim Form (find form below, only applicable if listed in the section)
10. I&O Medical Center Authorization Form

 

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

State Specific Claim Forms – Contact HR if you work in one of the following states:
Alaska
Arizona
Arkansas
California
Kansas
Illinois
Maryland
Ohio
Washington DC

Physician Panels

California
PSD Afloat West
DMDC Seaside
NMC San Diego
PSD Lemoore
PSD San Diego
San Diego Site Office – contact HR
WW Palo Alto
WW Twentynine Palms
WW Camp Pendleton Lakeside
WW Camp Pendleton Santa Margarita

Connecticut
PSD New London

Delaware
New Castle

Florida
City of Tampa – Fleet
City of Tampa – Fire
Martin County Warehouse
Mayport Site Office
PSD Jacksonville

Hawaii
MCB Kaneohe Bay

Kentucky
DEERS Fort Campbell
WW Fort Campbell

Maine
MEDOT Augusta
MEDOT Bangor
MEDOT Caribou
MEDOT Dixfield
MEDOT Scarborough
MEDOT Skowhegan

Maryland
DEERS Aberdeen Proving Ground
DEERS Fort Detrick
DEERS Fort Meade

Massachusetts
DEERS Natick
MBTA Albany
MBTA Arborway
MBTA Cabot
MBTA Everett
MBTA Fellsway
MBTA Lynn
MBTA McSweeney
MBTA Orient Heights
MBTA Quincy
MBTA Reservoir
MBTA Riverside
MBTA Southampton
MBTA Stoughton
MBTA Wellington

Michigan
Detroit Davision
Detroit Fire
Detroit Maintenance
Detroit Russell

North Carolina
Charlotte Airport
Charlotte – 12th
Charlotte – Atando
Charlotte – Louise
Charlotte – Sweden
Charlotte – Tuckaseegee
DEERS Fort Bragg
PSD Camp Lejeune

New Jersey
DEERS Picatinny Arsenal
NJDOT Bedminster
NJDOT Cherry Hill
NJDOT Fernwood
NJDOT Freehold
NJDOT Lafayette
NJDOT Lakewood
NJDOT Lodi
NJDOT Mays Landing
NJDOT Netcong
NJDOT Newark
NJDOT Vineland
NJDOT Woodbridge

New York
DEERS Fort Hamilton
DEERS West Point
DEERS West Point Cadet
Guthrie AHC
Rochester RTS

Ohio
Contact HR

Pennsylvania
DEERS Carlisle
DEERS Letterkenny
DEERS Tobyhanna
Defense Depot Camp Hill
Penske

Puerto Rico
WW Fort Buchanan – Contact HR

South Carolina
NWS Charleston

Texas
Dallas ISD & Bus – contact HR
Border Patrol El Paso – contact HR

Virginia
Corporate & HRSO
City of Harrisonburg
DEERS Fort Myer
DEERS Fort Lee
DEERS Fort Belvoir
Hampton Roads Naval Museum
MCB Quantico
PSD Norfolk
ServMart
VDOT Abingdon
VDOT Accomac
VDOT Alexandria
VDOT Amelia
VDOT Ashland
VDOT Bassett/Martinsville
VDOT Bedford
VDOT Bristol
VDOT Charlottesville
VDOT Chatham
VDOT Christiansburg
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

 

Safety Training Materials for Managers/Supervisors
Safety Training Sign-In Sheet
Contact HR for Safety Training Materials