Document your rights as an employee. Don't let your employer's discrimination or harrassment go unanswered. By getting access to these forms you can document your case to your employer. Also, more importantly you will have the paper work to support any future legal action.

Employee Right -Worker's Compensation

Worker's Compensation is the state regulated insurance program that pays medical bills and replaces a portion of lost wages for employees who are injured at work, or who have work related illnesses. Worker's Compensation also prohibits an employer from firing the employee, because he or she filed for Worker's Compensation.

Worker's Compensation is compromise based, where the employer provides for the continued income and medical care, while the employee does not sue the employer or ask for outrageous damages.

Worker's Compensation laws are enforced and administered by State's Workers ' Compensation Commission, board, or a comparable agency.

Required information for filing for Worker's Compensation claim

	Injured Employee's Name
	Injured Employee's Social Security Number
	Injured Employee's Mailing Address
	Injured Employee's Home or Work Phone Number
	Date of Birth
	Date of Injury/Disease
	Gender
	Occupation or Job Title
	Description of Accident
	Type of Injury/Disease and Part(s) of Body Affected
	Employer Policy Number

When the injured worker does not have the right to file for worker's compensation:

	Employee injured himself/herself while in a state of intoxication;
	Employee willfully attempted to injure themselves or unlawfully injure another person;
	Employee was injured for a personal reason by someone who was not a co-worker;
	Employee was injured while participating in a voluntary off-duty recreation, social, or athletic activity that was not part of the employee's duties;

Employers' Responsibilities:

Employers have certain responsibilities when the employee suffers on the job injuries.

	Employers are responsible to carry worker’s compensation.
	All medical bills payment because of work related injury.
	Payment of benefits as a substitute for lost wages.
	Employer is responsible to pay the permanently incapacitated employee lump sum amount.
	Employer is responsible for the payment of death benefits.

State Workers' Compensation officials

	ALABAMA
	Scottie Spates, DirectorWorkers' Compensation DivisionDepartment of Industrial Relations 649 Monroe Street Montgomery, AL 36131(334) 242-2868 or 1-800-528-5166
	ALASKA
	Paul Lisankie, Director Workers' Compensation DivisionDepartment of Labor 1111 West 8th Street, Suite 307 P.O. Box 25512 Juneau, AK 99802-5512(907) 465-2790
	ARIZONA
	Larry J. Etchechury, Director Industrial Commission 800 West Washington Street P. O. Box 19070 Phoenix, AZ 85007(602) 542-4411 or 1-800-544-6488
	ARKANSAS
	Olan Reeves, Chairman Workers’ Compensation Commission324 Spring Street P. O. Box 950 Little Rock, AR 72203-0950(501) 682-3930 or 1-800-622-4472
	CALIFORNIA
	Andrea Hock, Administrative Director Division of Workers' Compensation 455 Golden Gate Avenue, 9th Fl.San Francisco, CA 94102-3660(415) 703-4600 or 1-800-736-7401
	COLORADO
	Mary Ann Whiteside, Director Division of Workers' Compensation 1515 Arapahoe Street Denver, CO 80202-2117(303) 318-8700
	CONNECTICUT
	John A. Mastropietro, ChairmanWorkers' Compensation Commission21 Oak Street Hartford, CT 06106 (860) 493-1500 or 1-800-223-9675
	DELAWARE
	John Kirk III, Administrator Office of Workers’ Compensation 4425 N. Market Street, 3rd Floor Wilmington, DE 19802 (302) 761-8200 or 1-800-292-7885
	DISTRICT OF COLUMBIA
	James Jacobs, Director Office of Workers’ Compensation 64 New York Avenue, N.E., Washington, DC 20002 (202) 671-1000
	FLORIDA
	Tanner Holloman, Director Division of Workers’ Compensation 200 East Gaines Street Tallahassee, FL 32399-4220 (850) 488-2514 or 1-800-342-1741
	GEORGIA
	Carolyn Hall, Chairman Board of Workers' Compensation 270 Peachtree Street, NW Atlanta, GA 30303-1299 (404) 656-3875 or 1-800-533-0682
	HAWAII
	Gary S. Hamada, Administrator Disability Compensation Division Department of Human Resources Development 830 Punchbowl Street, Room 211 P. O. Box 3769 Honolulu, HI 96812 (808) 586-9151
	IDAHO
	R.D. Maynard, Chairman Industrial Commission 317 Main Street P. O. Box 83720 Boise, ID 83720-0041 (208) 334-6000 or 1-800-950-2110
	ILLINOIS
	Dennis Ruth, Chairman Industrial Commission 100 West Randolph Street Suite 8-200 Chicago, IL 60601 (312) 814-6611
	INDIANA
	G. Terrence Coriden, Chairman Workers' Compensation Board Room W-196 402 West Washington Street Indianapolis, IN 46204 (317) 232-3808
	IOWA
	Mike Trier, W.C. Commissioner Division of Workers' Compensation Workforce Development Department 1000 East Grand Avenue Des Moines, IA 50319 (515) 281-4748 or 1-800-562-4692
	KANSAS
	Paula Greathouse Division of Workers' Compensation 800 SW Jackson Street, Suite 600 Topeka, KS 66612-1227 (785) 296-3441 or 1-800-322-0353
	KENTUCKY
	Larry Greathouse Department of Workers Claims 657 Chamberlin Avenue Frankfort, KY 40601 (502) 564-5550 or 1-800-554-8601
	LOUISIANA
	Karen Winfrey, Assistant Secretary/Director Office of Workers' Compensation 1001 North 23rd Street P. O. Box 94094 Baton Rouge, LA 70802-9094 (225) 342-3111 or 1-800-756-7123
	MAINE
	Paul R. Dionne, Executive Director Workers' Compensation Board 27 State House Station Augusta, ME 04333-0027 (207) 287-3751 or 1-800-400-6854
	MARYLAND
	Thomas P. O'Reilly, Chairman Workers' Compensation Commission 10 East Baltimore Street Baltimore, MD 21201-3785 (410) 864-5100 or 1-800-492-0479
	MASSACHUSETTS
	Angelo Buonopane, Director Department of Industrial Accidents 600 Washington Street, 7^th Floor Boston, MA 02108-4220 (617) 727-6573 or 1-800-323-3249
	MICHIGAN
	Bureau of Workers’ Disability Compensation 7150 Harris Dirve P. O. Box 30016 Lansing, MI 48909 (517) 322-1296
	MINNESOTA
	Scott Brener, Commissioner Division of Workers' Compensation Department of Labor and Industry 443 Lafayette Road North St. Paul, MN 55155-4319 (651) 284-5017 or 1-800-342-5354
	MISSISSIPPI
	Ben Barrett Smith, Chairman Workers' Compensation Commission 1428 Lakeland Drive P. O. Box 5300 Jackson, MS 39296-5300 (601) 987-4200
	MISSOURI
	Renee Slusher, Director Division of Workers' Compensation Department of Labor and Industrial Relations P. O. Box 58 Jefferson City, MO 65102-0058 (573) 751-4231 or 1-800-775-2667
	MONTANA
	Jerry Keck, Administrator Employment Relations Division Department of Labor and Industry 1805 Prospect Avenue P. O. Box 8011 Helena, MT 59604-8011 (406) 444-1555 or 1-800-772-2141
	NEBRASKA
	Michael K. High, Presiding Judge Workers' Compensation Court Capitol Building P. O. Box 98908 Lincoln, NE 68509-8908 (402) 471-6468
	NEVADA
	Roger Bremer, Administrator Division of Industrial Insurance Relations 400 W. King Street, Suite 400 Carson City, NV 89703 (775) 684-7260 or 1-800-553-5115 (Northern region) 1-800-767-1446 (Southern region)
	NEW HAMPSHIRE
	Kathryn Barger, Director Workers' Compensation Division Department of Labor 95 Pleasant Street Concord, NH 03301 (603) 271-3176 or 1-800-272-4353
	NEW JERSEY
	Peter Calderone, Director/Chief Judge Division of Workers' Compensation Department of Labor P. O. Box 381 Trenton, NJ 08625-0381 (609) 292-2414
	NEW MEXICO
	Alan Varela, Director Workers' Compensation Administration 2410 Centre Drive, SE P. O. Box 27198 Albuquerque, NM 87125-7198 (505) 841-6006 or 1-800-255-7965
	NEW YORK
	David Wehner, Chairman Workers' Compensation Board 20 Park Street, Room 400 Albany, NY 12241 (518) 474-6670
	NORTH CAROLINA
	Buck Lattimore, Chairman Industrial Commission 4319 Mail Service Center Raleigh, NC 27611 (919) 807-2500
	NORTH DAKOTA
	Charles Blunt, Executive Director Workforce Safety and Insurance 1600 East Century Avenue, Suite 1 Bismarck, ND 58503-0644 (701) 328-3800
	OHIO
	James Conrad, Administrator Bureau of Workers' Compensation 30 West Spring Street Columbus, OH 43215-2256 (614) 466-8751 or 1-800-644-6292
	OKLAHOMA
	Richard Blanchard, Presiding Judge Workers' Compensation Court 1915 North Stiles Avenue Oklahoma City, OK 73105-4904 (405) 522-8600 or 1-800-522-8210
	OREGON
	John Shilts, Administrator Workers' Compensation Division 350 Winter Street, NE Salem, OR 97309 (503) 947-7500
	PENNSYLVANIA
	John T. Kupchinsky, Director Bureau of Workers' Compensation Department of Labor and Industry 1171 So. Cameron Street, Rm. 324 Harrisburg, PA 17104-2501 (717) 772-4447 or 1-800-482-2383
	PUERTO RICO
	Basilio Rivera, Chairman Industrial Commission G.P.O. Box 364466 San Juan, PR 00936-4466 (787) 781-0545
	RHODE ISLAND
	E. Jean Severance, Associate Director Division of Workers' Compensation Department of Labor and Training P. O. Box 20190 Cranston, RI 02920-0942 (401) 462-8100
	SOUTH CAROLINA
	J. Alan Bass, Chairman Workers' Compensation Commission 1612 Marion Street P. O. Box 1715 Columbia, SC 29201 (803) 737-5700 or 1-800-868-4244
	SOUTH DAKOTA
	James Marsh, Director Division of Labor & Management Department of Labor 700 Governors Dr., Kneip Bldg. Pierre, SD 57501-2291 (605) 773-3681
	TENNESSEE
	Sue Ann Head, Director Division of Workers' Compensation Department of Labor and Workforce Development Andrew Johnson Tower, 8th Floor 710 James Robertson Parkway Nashville, TN 37243-0655 (615) 532-4812 or 1-800-332-2667
	TEXAS
	Mike Hachtman, Chairman Workers' Compensation Commission 7551 Metro Center Drive Austin, TX 78704-7491 (512) 804-4000 or 1-800-252-7031
	UTAH
	Joyce Sewell, Director Industrial Accident Division Labor Commission 160 East 300 South, 3rd Floor P. O. Box 146610 Salt Lake City, UT 84114-6610 (801) 530-6800 or 1-800-530-5090
	VERMONT
	Laura Collins, Interim Director Workers’ Compensation Division National Life Building, Drawer 20 Montpelier, VT 05620-3401 (802) 828-2286 or 1-800-734-2286
	VIRGINIA
	Lawrence D. Tarr, Chairman Workers’ Compensation Commission 1000 DMV Drive Richmond, VA 23220 (804) 367-8600
	VIRGIN ISLANDS
	Jeanette Encarnacion, Director Workers' Compensation Division Department of Labor 3012 Vitraco Mall - Golden Rock St. Croix, VI 00820-4666 (809) 692-9390 or (809) 773-1994, Ext. 238
	WASHINGTON
	Robert Malooly Insurance Services Division Department of Labor and Industries 7273 Linderson Way, SW Tumwater, WA 98501-4850 (360) 902-4213 or 1-800-547-8367
	WEST VIRGINIA
	Greg Burton, Commissioner Workers' Compensation Division 4700 MacCorkle Avenue, SE Charleston, WV 25304 (304) 926-5048 or 1-800-628-4265
	WISCONSIN
	Francis Huntley-Cooper, Administrator Workers' Compensation Division Department of Workforce Development 201 East Washington Avenue P. O. Box 7901 Madison, WI 53707 (608) 266-1340
	WYOMING
	Gary W. Child, Administrator Workers’ Safety & Compensation Division 1510 East Pershing Boulevard Cheyenne, WY 82002-0700 (307) 777-7441

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