Workers' Compensation Guidance & Forms


Ensure you review the correct information for your state. Direct any questions to hr@wellhaven.com. Examples of completed forms are available below.

For WA State Only	When a workplace injury occurs, a health care provider will determine and certify whether the injury is work-related, and help initiate any processes. Learn more: WA State Workers' Comp Claim Information. NOTE: Complete the OSHA Module in Paycom for all reportable injuries PAYCOM WORKPLACE INJURY MODULE INSTRUCTION GUIDE.pdf Review L&I FAQs - What to expect L&I - What to expect WA State – L&I – Contact Information Phone: 360-902-5800
For ALL other states: Follow the steps below
Step 1	Review the PM/PD Checklist	Work Comp - PM Checklist.pdf

Step 2	Complete the Injury Claim Form	Arizona First Report of Injury Form Colorado First Report of Injury Form Minnesota First Report of Injury Form Montana First Report of Injury Form Nevada First Report of Injury Form Oregon Report of Injury Form

Step 3	Print/provide to injured employee: Injured Employee & Return to Work Form Workers' Comp Resource Guide	Work Comp - Injured Employee Worksheet & RTW Form - Fillable Hanover Resource Guide.pdf

Step 4	Print/provide to injured employee: Employee's job description to bring when seeking medical attention	WellHaven Job Descriptions

Step 5	Print/provide to injured employee: Employee's state statutes information	Arizona Workers' Compensation Statutes Colorado Workers' Compensation Statutes Minnesota Workers' Compensation Statutes Montana Workers' Compensation Statutes Nevada Workers' Compensation Statutes Oregon Workers' Compensation Statutes

Step 6	Have witness complete the Witness Statement Form	Witness Statement- Fillable.pdf

Step 7	Supervisor to complete the Incident Investigation Report	Work Comp Supervisor Investigation Report.pdf

Step 8	Submit all completed documentation to Hanover.	Hanover – Contact Information Phone: 800-628-0250 Fax: 800-762-7788 Email: WCNewLosses@Hanover.com WellHaven Policy # WZ2M13758900

Step 9	Complete the OSHA Module in Paycom for ALL reportable injuries	PAYCOM WORKPLACE INJURY MODULE INSTRUCTION GUIDE.pdf

Examples	For additional help: Review examples of completed documents or contact HR@wellhaven.com	Work Comp - Examples of Completed Documents.pdf

Ensure you review the correct information for your state.

For WA State Only

For ALL other states: Follow the steps below

Step 1

Step 2

Step 3

Step 4

Step 5

Step 6

Step 7

Step 8

Step 9

Examples

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