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

 

California

Afloat West San Diego
DMDC Seaside
NMC – San Diego
PSD NAS Lemoore
PSD San Diego
San Diego Site Office
WW Palo Alto
WW Twentynine Palms

WW Camp Pendleton Lakeside
WW Camp Pendleton Santa Margarita

Colorado

OWF Fort Carson
WW Colorado Springs
Connecticut
PSD New London 
Delaware
Florida
City of Cape Coral
City of Tampa – North Clark
City of Tampa – Chestnut Street
Martin County Utilities Warehouse
Mayport Site Office
PSD Jacksonville

Georgia

WW Fort Stewart
Hawaii
        WW Kaneohe Bay
Indiana
NACFAC Midwest Det Crane 
Kentucky
WW Fort Campbell – Contact HR

Maine

Maryland

Massachusetts

        MBTA Albany Garage
MBTA Arborway Bus Garage

 

Michigan
City of Detroit

City of Detroit – Fire
City of Detroit – Street Maintenance
North Carolina
Charlotte Douglas Airport
PSD Camp Lejeune
WW Fort Bragg
City of Charlotte – Louise
City of Charlotte – Sweden
City of Charlotte – Tuckaseegee

City of Charlotte – 12TH ST

PENSKE BERWYN
Rhode Island
PSD Newport
NWS Charleston
Texas
Dallas Independent School District – Contact HR
El Paso – Contact HR
WW Fort Hood – Contact HR
Virginia

ATAC Norfolk
CORPORATE
City of Harrisonburg
E2I HEADQUARTERS
FLC Norfolk
Hampton Rds Naval Museum
HAMPTON ROADS SITE OFFICE
MCB Quantico
MTF Langley AFB
PSD Norfolk
PSD Little Creek
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

Washington
       Contact HR

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