This notice must be posted and maintained by the employer in one or more conspicuous places. NOTICE Your employer is subject to the Kansas Workers Compensation law which provides compensation for job-related injuries. 1-800-332-0353 WHAT TO DO IF AN INJURY OCCURS ON THE JOB Notify your employer immediately. Your claim may be denied if you fail to tell your employer within 10 DAYS of the injury. For just cause you may have 75 days to tell the employer of your injury. Thereafter you must file a written claim within 200 days of the accident or last date benefits are paid. Submission of Employer's Report of Accident does not constitute a written claim. MEDICAL BENEFITS An employer is required to furnish all necessary medical treatment and has the right to designate the treating physician. If the employee seeks treatment from a doctor not authorized by the employer, the employer or its insurance carrier is only liable up to $500.00. WEEKLY BENEFITS Benefits are paid by the employer's insurance carrier or self-insurance program. Injured workers are not entitled to compensation for the first week they are off work unless they lose three consecutive weeks. The first compensation payment is normally due at the end of the 14th day of lost time. An injured employee is entitled to a weekly amount of 66 2/3% of his average weekly wage up to a maximum of 75% of the state's average weekly wage. These benefits are subject to legislative changes and for the latest information on benefit levels, please contact the Division at the address and phone number below. If the injury results in permanent disability, the Kansas compensation law provides for additional benefits. Helpful Information – Ombudsman Contact the Ombudsman/Claims Advisory Section at the Division of Workers Compensation immediately if you do not receive compensation in a timely manner. The Division has full-time personnel who specialize in aiding injured workers with claim problems. They can give information on what benefits an injured worker is entitled to receive. Such problems as benefits not being paid on time, unpaid medical bills, questions in regard to proper settlement amounts, etc., should be brought to the attention of the Ombudsman/Claims Advisory Section. Our toll free telephone number: 1-800-332-0353. WHERE TO GET HELP WITH YOUR CLAIM: Current claims are being administered by ______________________________________________________________________ The claims office is located at ( ) telephone _______________________ INFORMACIÓN SOBRE COMPENSACIÓN DE TRABAJADORES La ley exige que cuando un trabajador llega a sufrir un Su reclamo puede ser negado si usted no notifica (avisa) a accidente, una herida, o una enfermedad a causa de su su empleador (patrón) dentro de 10 días del accidente o empleo, el empleador debe proporcionarle al trabajador lastimadura. Por buena causa usted puede tener 75 días incapacitado tratamiento médico y otros beneficios sin para avisarle a su empleador (patrón) de su accidente o ningún costo al trabajador. El trabajador incapacitado lastimadura. De allí en adelante, usted debe entregar tiene derecho a recibir un sueldo reducido, mientras un aviso por escrito dentro de 200 días del accidente se restablece. La ley tambien protege los derechos del o último día que recibío tratamiento medico, o que trabajador incapacitado en otras maneras, por ejemplo: recibío beneficios. Un reporte de accidente no se prohibe el desempleo de un trabajador solo por constituta un aviso por escrito. Para mas información haber reclamado los beneficios de la compensación de acerca de los beneficios o para recibir asistencia con trabajadores. Reporte cada accidente o lastimadura un reclamo, llame al teléfono 1-800-332-0353 (gratis) industrial inmediatamente al patrón, o al empleador. o al 785-296-2996. Division of Workers Compensation 800 S.W. Jackson Street, Suite 600, Topeka, KS 66612-1227 Phone: 785-296-2996 Web site: www.dol.ks.gov • E-mail: wc@dol.ks.gov K-WC 40 (Rev. 3-08) Persons with impaired hearing or speech utilizing a telecommunications device may access the above number(s) by using the Kansas Relay Center at 1-800-766-3777. American LegalNet, Inc. www.FormsWorkflow.com