Risk Management

 

Employee’s Notice of Key Information Regarding
Workers’ Compensation

This notice and attached information has been prepared to provide you with information concerning your rights and your obligations under the Industrial Insurance Laws (Title 51) of the State of Washington. Please read them carefully.

General Information

• The Renton School District is a self-insured employer. This means the District pays your workers’ compensation benefits, not the State.
• All workers in the State receive the same required minimum benefit coverage. The District pays benefits above the minimum required. The Supplemental Pension and Asbestos premium deduction is still required, but is supplemented by Renton School District. The deduction amount is determined by the Department of Labor and Industries and is subject to change annually. Based upon the amount effective January 1, 2009, the total employee’s deduction is just over 4 cents per hour worked and is matched by Renton School District.
• The District contracts with a service company, Tristar, which administers all claims.
• The Self-Insurance Office of the Department of Labor and Industries makes all actions and final decisions on claims involving time loss.

Your Rights and Responsibilities

• You must immediately report your injury/disease to your supervisor.
• You have up to one year from the date of injury to actually file a claim.
• To file a claim:
  • Complete a “Self Insurer Accident Report (SIF-2)” (available from the Renton School District Workers Compensation and Leaves Coordinator or Tristar) and submit immediately to Human Resources.
    • Take a copy of the “Provider’s Initial Report” with you to a practitioner of your choice.
    • Be treated by a practitioner for your injury/disease.
    • Any change in your treating practitioner must be pre-approved by a Tristar Claims Administrator.
    • You should keep the District advised of your progress. Report anticipated length of absence.
    • Your physician must provide medical progress reports.
    • If your claim is rejected because your injury/disease is not work-related, you may be required to repay the conditional payments you have received.

Medical Costs

• Your medical service and related benefit expenses must be the result of a qualifying work-related injury/disease.
• The District will pay for medical services and related benefits as determined by law and authorized by the Department of Labor and Industries until the claim is closed.
• You are not to be charged for any authorized treatment.

Time Loss compensation

• To be eligible for time loss, you must be under the care of an authorized practitioner who certifies that you are temporarily disabled and unable to return to work due to this injury/disease.
• The amount you receive is dependent upon your marital status and number of dependents. The amount available ranges from 60-75% of your base wages.
• RESP & Prof Tech EMPLOYEES ONLY: Beginning the day of injury, the District will allocate 40% of a day’s sick/vacation leave for every regularly scheduled work day you receive workers’ compensation time loss payments until such accumulated sick/vacation leave is exhausted, except that calendared holidays will be paid as holiday pay. You may choose, in writing, to use sick leave and, instead, receive workers’ compensation time loss payments only in compliance with Industrial Insurance Laws of the State of Washington.
• ALL OTHER EMPLOYEES: Beginning on the day of injury, the District will pay full salary and benefits during the first 60 calendar days for eligible time loss. For time loss, which extends beyond 60 calendar days from the date of injury, you may make a one-time election regarding use of your accumulated sick leave beginning with the 61st day.
• You will receive workers’ compensation only in compliance with Industrial Insurance Laws of the State of Washington and your collective bargaining agreement.
• Time loss benefits from the District will continue until:
  • You return to regular duty, with a doctor’s release;
  • You are released by your doctor for light duty and light duty is assigned by the District;
  • You refuse to accept a light duty assignment, or
  • You refuse to follow laws governing treatment of on-the-job injuries.
• The method by which Renton School District determines Time Loss Certification includes, but is not limited to:
  • Certificate of Disability
  • Medical Reports
  • Release for Work Slip
  • Self Insurer Accident Report (SIF-2)
  • Phone Calls
• Our Self-Insured Program Administrators, Tristar, will obtain this information.

Claim Closure

• Your claim will be submitted for closure when no further curative treatment is indicated.
• Permanent Partial Disability Awards are determined by the Department of Labor and Industries and may be awarded in the case of permanent percent of loss in function of a body part due to industrial injury or disease.

Reconsideration’s and Appeals

• The Department of Labor and Industries, not the Renton School District issues all orders on Industrial Insurance claims.
• If you do not agree with an order on your claim, you may file a protest in writing within 60 days of receipt of the order to:

Administrator, Self-Insurance Section
Department of Labor and Industries
PO Box 44892
Olympia, WA 98504-4892

For any questions or concerns regarding an injury claim, contact the District’s claims administrator listed below. Remember, keeping us informed will help to eliminate delays and will help to ensure prompt handling of your claim.

Tristar
attn: Amy Stone
P.O. Box 2805
Clinton, IA. 52733-2805
971-925-1300 EXT 1920

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EMPLOYEE:

If you have experienced an on-the-job injury please follow the following steps outlined in this information so we can do everything possible to provide a safe work site as well as:

• Preserve your wages to the extent possible,
• Assure continuation of your health insurance coverage, and,
• Contain the cost of both yours and RSD workers compensation costs. (Note the L&I deduction on your paycheck).
• If you will need medical care related to your workers’ compensation claim you must verify that your doctor or health-care provider has enrolled in L&I’s Medical Provider Network.

Why is it important to know if your provider is in the network?

Only network providers can deliver ongoing medical treatment for your work-related injury or condition.

How to verify if Provider is in-Network:

1. Check your provider’s network status at www.findadoc.lni.wa.gov If your provider is in the network, no further action is needed.
2. If your provider has not applied to the network, encourage them to do so. If they do not apply, you must transfer to a network provider.
3. If your provider does not plan to apply, transfer to a network provider.
   • Find network providers in your area using www.findadoc.lni.wa.gov
   • Contact new providers to make sure they will accept you as a patient and make an appointment.
   • Once you have an appointment, request a transfer of care by contacting your employer or third-party administrator.

Read the enclosure for more information about the network.

• What is L&I’s medical provider network?
• Using network providers for all or your care.
• Which provider types must join the network?

After verification follow these steps:

1. Provide District information to your doctor on your first visit.
2. Have your doctor complete the “Provider’s Initial Report” and make any comments he/she feels are necessary for you to safely return to work. Remind your doctor that Renton School District has a light duty program and should be able to tailor to your needs.
3. Return this folder to your supervisor on the same day you see your doctor and complete the “On-The-Job-Injury” report. If you are unable to return that day, notify your supervisor by phone immediately, and then follow the same procedures as if you were ill.
4. DO NOT PERFORM WORK BEYOND YOUR MEDICAL RESTRICTIONS.
5. If you are released to light duty, please contact Human Resources immediately to determine if light duty work is available.
6. If you have any questions you may contact the Renton School District Workers Compensation and Leave Coordinator:

Renton School District Administration Office

Ryan Rudolph
300 SW 7th Street
Renton WA 98057
Phone: 425.204.2298
Email

Complete the “Self Insurer Accident Report (SIF-2)" and return within 24-hours of your accident.

Do not leave this form with your doctor.

 

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The following are steps to taken to file an On-The-Job-Injury report (Workers’ Compensation Claim).

OFFICE MANAGER/ADMINISTRATOR WILL DO THE FOLLOWING:

1. Give the employee a link to this Workers’ Compensation information. (Red folder)
2. After employee has completed steps 1 through 3 (if applicable), outlined below, have the employee’s supervisor complete, sign and date the Employer Section of the SIF-2 form and complete, sign and date a Supervisor On-The-Job Injury report. You do not need to complete any wage or hour information.
3. Mail the completed, signed SIF-2 form, along with the Employee On-The-Job-Injury report and any other claim related paperwork directly to Human Resources.

EMPLOYEE PLEASE DO THE FOLLOWING:

1. The employee completes the Employee On-The-Job-Injury report and has their supervisor complete the Supervisor On-The-Job-Injury report. All forms must be signed and dated by the employee and supervisor and the location where the injury occurred.
2. If outside medical treatment is required obtain a Self-Insurer Accident Report (SIF-2), from the Renton School District Workers Compensation and Leaves Coordinator or Tristar. Complete the employee portion of the form and return the form directly to the Human Resources department following the initial provider visit.
3. The completed, original “Provider’s Initial Report” form is turned in with all claim related paperwork, a copy should be kept by the employee and the physician.

If an Employee is not filing a claim, then an Employee On-The-Job-Injury report and Supervisor On-The-Job-Injury report must be completed, signed, dated and returned to Human Resources.

If you have any questions, please contact the District’s Workers Compensation and Leave Coordinator:

Ryan Rudolph, CDMS, CEAS III

Workers Compensation and Leave Coordinator
300 SW 7th Street
Renton WA 98057
Phone: 425.204.2298
Email

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