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. 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. 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 – Contact HR if you work in one of the following states:
Alaska
Arizona
Arkansas
California
Kansas
Illinois
Maryland
North Dakota
Ohio
Texas
Washington DC
Wyoming

Physician Panels

California
DMDC Seaside
NMC San Diego
PSD Lemoore
PSD North Island
WW Twentynine Palms
WW Camp Pendleton Lakeside
WW Camp Pendleton Santa Margarita

Connecticut
PSD New London

Delaware
New Castle

District of Columbia
DOT Federal Railroad Administration
Bureau of Labor Statistics

Florida
City of Tampa – Fleet
City of Tampa – Fire
City of Tampa – Hanna
City of Fort Lauderdale
Martin County Warehouse
PSD Jacksonville
PSD Pensacola

Hawaii
MCB Kaneohe Bay

Idaho
Idaho National Labs

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

Massachusetts
MBTA Albany
MBTA Arborway
MBTA Cabot
MBTA Capital Spares
MBTA Everett
MBTA Fellsway
MBTA Lynn
MBTA McSweeney
MBTA Orient Heights
MBTA Quincy
MBTA Reservoir
MBTA Riverside
MBTA Somerville
MBTA Southampton
MBTA Stoughton
MBTA Wellington