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Notice Form. This is a Kansas form and can be use in Workers Compensation.
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Tags: Notice, K-WC 40, Kansas Workers Compensation,
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.
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