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Form No. LIBC-500 - Contact information for PALCS Workers Compensation Company (Zenith Insurance Company)
Rights and Duties form - To be signed and submitted to sheiland@palcs.org when an accident report is filed.
I was injured at work. What should I do?
If you need immediate medical treatment and your injuries are life threatening or deemed serious by you, seek treatment right away at the nearest Emergency Room and then complete the applicable steps below as soon as you are able.
If you are incapacitated to the degree that you cannot complete the steps below, but have a friend, family member and/or designee that would help facilitate communication between yourself and PALCS, please have them contact the Director of HR (sheiland@palcs.org) at 610-701-3333 Ext 1127
If your injury is not deemed life threatening or serious, but you do still require medical attention, please refer to the following resources to find a location near to you to obtain treatment.
List of approved medical providers - NOTE - TO BE COVERED UNDER WORKERS COMPENSATION, IT IS IMPORTANT TO USE A MEDICAL PROVIDER THAT IS ALIGNED TO OUR WORKERS COMPENSATION PROVIDER
Approved providers by school location:
If you live outside of the zip code areas provided in the listings above, you may search for an approved provider in another area by using this link.
If Circumstances allow, please complete the information in the following section prior to or while at the medical facility so that a workers compensation claim number may be obtained and can be given to the medical facility for billing purposes. If circumstances do not allow completion of the following steps, then simply let them know that you will be filing a claim and you can provide the medical facility the name of our workers compensation company and contact information.
Zenith Insurance Company - ZNAT Insurance Company
PO Box 1558
Sarasota, FL 34230
877-311-0703
Steps to report claim and obtain workers compensation claim number:
Steps to report claim and obtain workers compensation claim number:
Once you are able or if immediate medical attention was not needed, please complete the following steps:
(Note: these steps should be followed regardless of the severity of the injury of whether you feel you need treatment now or in the future)
Please complete this form within 24 hours (click here).
The importance of doing this within 24 hours is to document the time, place and circumstances of the injury in the event that a claim may be needed at a later date.
A copy of the information submitted in this form will be sent to the Director of HR and you will be contacted to provide further information on submitting a workers compensation claim if needed.
Acknowledge and sign the Rights and Duties form and email to the Director of HR at sheiland@palcs.org.
The provided “panel” of providers referenced in this form is provided below.
If a workers compensation claim is needed, it will be submitted by the HR Department and the sooner that you are able to complete the injury form and/or contact the Director of HR, the sooner the claim can be submitted and a claim number can be provided that you can provide to your medical provider when you receive treatment.
PLEASE NOTE THE FOLLOWING:
If you are faced with a medical emergency, you may secure initial emergency treatment from any of the above mentioned emergency facilities or any other emergency facility. However, any follow-up care to the emergency treatment must be with a designated health care provider.
If you choose to treat with an out of state provider, you may be subject to balance billing.
For medical treatment to be paid by your employer:
You must select one of the physicians or physician groups listed within the approved Zenith Insurance Company approved physicians or physician groups.
You must continue to visit one of the physicians listed or any specialist to which that provider refers you, if you need treatment, for Ninety (90) days from the date of your first visit. This requirement is in conformance with the Pennsylvania Workers’ Compensation Act, Section 306 (F) (1) (i).
After Ninety (90) days, if you still need treatment, you may continue with the same physician or you may choose to go to another physician or health care provider for treatment. If you decide to go to another provider, you must notify your employer of this action within five (5) days of your visit.
Your bills will be paid if your physician or healthcare provider reports as required (within ten days after your first visit and at least once a month as long as treatment continues). You must notify the new provider that these reports are to be submitted to the following address:
Zenith Insurance Company - ZNAT Insurance Company
PO Box 1558
Sarasota, FL 34230
877-311-0703
Do I have to report an injury at work?
Yes, all injuries sustained at work, whether or not you plan to seek treatment, are to be reported utilizing this form. You must also notify your supervisor after completing this form.
I didn’t realize I was injured until a few days after my accident, can I still make a claim?
Yes, you can still file a workers compensation claim. However, you should always report your injury as soon as you possibly can, even if you do not think that you were hurt. When you do not report your injury on the same day that it happened, you can lose or jeopardize your rights to receive workers compensation benefits.
Do I have to go to a certain doctor for treatment?
In an emergency, seek treatment at the nearest emergency room. You cannot seek emergency care at an urgent care facility unless it is on the approved provider list. For non-emergencies and any treatment follow up, you must seek medical treatment for your claimed injury with one of the providers listed within this document within ninety (90) days from the date of your first visit.
I am able to return to work but with modifications and/or accommodations. What should I do?
Contact the Director of HR (Seth Heiland at sheiland@palcs.org or at 610-701-3333, Ext 1127). The Director of HR will need to see a copy of the doctor’s note and the restrictions. In most cases, the Director of HR will set up an Interactive Meeting and have the employee come in to meet to review the restrictions. There is no guarantee that the restrictions will be able to be met by PALCS. Should PALCS be unable to meet the restrictions, the employee will remain out of work and continue with the plan of treatment with the goal of a full duty release.
Can my workers comp claim be denied?
Yes, claims submitted as a workers compensation claim can be denied by the workers comp insurance company, Zenith Insurance Company. Denied medical claims will result in the employee having to submit their claims for medical treatment to their individual medical insurance policy. In some instances, the workers comp carrier may accept claims for medical only and not for loss of wages.
If the worker comp carrier accepts the medical claim but does not accept loss of wages, what happens?
If your claim is denied for loss of wages and you are medically unable to return to work, the employee must use accrued sick, personal and vacation days to cover the absence and will receive pay during that time. Should you be medically unable to return to work at the end of your eligible district paid time off, your leave will be designated as unpaid FMLA, assuming you meet the FMLA guidelines of length of employment and hours worked. FMLA will hold your position and health benefits for up to 60 work days.
When is an injury not covered?
The most frequent examples of an injury not covered by workers compensation are when the employee is present in a district building as a member of the general public, not as an employee; when coming to and from work and not on district property; when there is no mechanism of injury; or when on site volunteering their time (not working in an employee capacity).
For any additional questions, please contact the Director of HR at 610-701-3333, Ext 1127 or sheiland@palcs.org.
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