Accident Report Form (PDF)
Medical Center Environmental Health & Safety
(212) 305-6780
Medical Center Human Resources
(212) 305-3819
Shawn Kincaid
Human Resources, Benefits Department
Phone: (212) 851-0645
Fax: (212) 851-7069
Report the injury to your supervisor promptly (if you haven’t already done so).
Fill out a Department Accident Report Form for Workers’ Compensation Benefits. You can get this form from your supervisor. It must be completed by you and your supervisor without delay and faxed directly to Shawn Kincaid at (212) 851-0645 for processing. Keep a copy of this form. Employee and Labor Relations will send the form to the insurance carrier and the New York State Workers’ Compensation Board. Late reporting may result in a delay in processing your claim.
Get medical attention as soon as possible. Your options are:
Tell the doctor you were injured at work. Make sure the doctor is authorized by the Worker’s Compensation Board to treat work-related injuries and will file all the necessary medical reports.
Do not pay the doctor or hospital and do not let them charge your medical treatments to your health plan, unless it is an emergency. Save all receipts for treatments (emergency room prescriptions, etc.).
Advise the doctor to send the report (“C-4” form) and bills to the University’s insurance carrier:
Chubb Services Corporation
P.O. Box 1618
Warren, NJ 07059
Phone: (908) 903-2000
Fax: (908) 903-7858
In addition to filling out the necessary forms, you must provide your supervisor with medical documentation (a doctor’s note) to cover your absence as well as keep him/her properly updated with respect to your anticipated return to work date.
Do not fill out a disability form (DB-450) unless you receive a “C-7” (Notice of Controversion) from the insurance carrier (Chubb Services Corporation)or the Workers’ Compensation Board.