Business Office
Andrews Independent
School District
405 NW 3rd Street
Andrews, Texas 79714
Andrews Independent School District
(AISD) provides Workers’ Compensation Insurance, as required by Federal and
State Regulations, to protect its employees in the event of work-related injury
or illness. This is the District’s responsibility to each employee. Our
current Workers’ Compensation carrier is Trinity Universal Insurance Company
(Unitrin). This coverage is effective from September 1, 1999. Unitrin will
handle any injuries or illnesses that occur on or after that date.
As an employee of AISD, you may elect
to retain your common law right of action if, no later than five (5) days after
beginning employment, you notify Andrews ISD in writing that you wish to retain
your common law right to recover damages for personal injury. If you elect your
common law right of action, you cannot obtain workers’ compensation income or
medical benefits if you are injured.
Should an employee be injured on the
job, the following guidelines must be used to report the injury:
1. Your immediate supervisor and/or
principal should be notified of the injury within 24 hours. If you are
injured over the weekend (for example, on a school sponsored trip, etc.),
please contact your supervisor by Monday morning.
2. You must complete a WC-1 Notification
of Injury Report and give to your supervisor. Be sure to sign the
report. All supervisors must also sign this report.
3. If you are a supervisor,
you must complete a LC-6-94 Supervisor’s Injured Employee Investigation
Form and turn into the Business Office so that the Workers Comp. Carrier
can be notified of the injury. PLEASE CALL THE BUSINESS OFFICE TO REPORT
THE INJURY ALSO. Many times the Hospital or Doctor’s offices will call
to verify the injury and the Insurance Department has not been notified,
which causes a delay in services.
4. You can get more information
about Workers’ Compensation rights from any office of the Texas Workers’
Compensation Commission, or by calling 1-800-252-7031. The Commission
provides free information about how to file a claim, as well as, explaining
your rights and responsibilities under the Workers’ Compensation Act.
5. The Commission has established a
24-hour toll-free telephone number for reporting unsafe conditions in the
workplace that may violate occupational health and safety laws. Employers
are prohibited by law from suspending, terminating, or discriminating
against any employee because he or she in good faith reports an alleged
occupational health or safety violation. Contact the
Division of Workers’ Health and
Safety at 1-800-452-9595.
Failure to follow the above
guidelines will result in the declination of worker’s compensation insurance
benefits.
I have read and understood the above
notice.
Printed Employee’s Name:
Signature of Employee:
Signature of Employer’s
Representative:
Date Signed:
Andrews Independent
School District
Notification of Injury Report
Injured Employee:
Assignment:
Date of Injury: Date of Report:
Describe incident causing injury:
Give specific details relating to
injury:
Injured Employee signature Supervisor
signature
NOTE:
All injuries occurring on the job must be reported to immediate supervisor
within 24 hours or the Workers’ Compensation claims will not be accepted.
Please submit a copy of this report to the following offices:
Injured employee
Campus supervisor
Business Office – Insurance Dept.
