Notice Of Compliance Form. This is a District Of Columbia form and can be use in Workers Comp.
Tags: Notice Of Compliance, 1 DWC, District Of Columbia Workers Comp,
DEPARTMENT OF EMPLOYMENT SERVICES OFFICE OF WORKERS' COMPENSATION DISTRICT OF COLUMBIA GOVERNMENT 4058 MINNESOTA AVENUE, N.E.· WASHINGTON, DC 20019 · (202) 671-1000 · (202) 671-1929 (fax) Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalities include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. NOTICE OF COMPLIANCE TO EMPLOYEES 1. You are required by law to report promptly to your employer and the Office of Workers' Compensation an occupational injury or disease, even if you deem it to be minor. Form No. 7 DCWC, Notice of Accidental Injury or Occupational Disease, to be obtained from the employer or the Office of Workers' Compensation, must be used for that purpose. After you have completed and signed it, you should mail it to the Office of Workers' Compensation at the above address, and to your employer. 2. You are entitled, if required, to the services of a physician or hospital of your choice and lost wages. Call (202) 671-1000 for information. 3. You may not sue your employer as a result of a work-connected injury or disease by reason of your exclusive remedy under the Workers' Compensation Law. 4. In order to preserve your right to benefits under the DC Workers' Compensation Law, you must file a written claim on Form No. 7A DCWC, Employee's Claim Application, within one (1) year after your injury, or within (1) year after the last payment of benefits. 5. If you desire information regarding your rights and obligations prescribed by law, you may call your employer first. If you need further information you may call the Office of Workers' Compensation at (202) 671-1000. 6. The law gives you the right to be represented if you so desire. TO EMPLOYERS 1. You are required to have Workers' Compensation insurance coverage if you have 1 or more employees. 2. You are required to display this poster at each worksite so that it will be of the greatest possible benefit to your employees. 3. You must file an Employer's First Report of Injury or Occupational Disease, Form No. 8 DCWC, with the Office of Workers' Compensation, copy to the nearest claim office of your insurer, on all occupational injuries or disease, as soon as possible, but no later than 10 days after the date of knowledge thereof. 4. Your employee must file Form No. 7 DCWC, Employee's Notice of Accidental Injury or Occupational Disease. Please provide your employee with Form No. 7 DCWC and direct them to complete it and return it to you and the Office of Workers' Compensation. Once you have received notice from the employee, you are required to send the employee a notice of his/her rights and obligations by certified mail, return receipt requested. 5. You are required to report to the Office of Workers' Compensation, and your insurer, and disability of more than 3 days which was not previously reported, as soon as possible, but no later than 10 days after the date of knowledge thereof. 6. You are required to furnish, or cause to be furnished, reasonable medical and hospital services, other remedial care or vocational rehabilitation, and various types of disability compensation, to an injured or disabled employee. 7. You are required to obtain from the insurer identified below a supply of all required Workers' Compensation Forms, or you may download the forms and notice mentioned above at our website http://does.dc.gov NOTICE: Violation of the various provisions of the Workers' Compensation law provides for civil penalties. The undersigned employer hereby gives notice of compliance with all provisions of the Workers' Compensation Law and Administrative Regulations NAME OF INSURANCE COMPANY NAME OF EMPLOYER BY ________________________________________ ____________________________________________ (if number unknown, employer to request from IRS) Employer ID Number THIS NOTICE IS TO BE POSTED CONSPICUOUSLY IN AND ABOUT EMPLOYER'S PLACE(S) OF BUSINESS FORM NO. 1 DCWC Revised June, 2002 American LegalNet, Inc. www.FormsWorkFlow.com