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Allan L. McVey
Insurance Commissioner
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WORKPLACE WORKERS’ COMPENSATION NOTICES (POSTERS)

The workplace workers’ compensation notices (posters) required by statute are NOT subject to OIC review or approval

West Virginia Code § 23-2C-15(b) requires, in part, that:

“Every employer shall continuously post a notice upon its premises in a conspicuous place identifying its workers’ compensation insurer. The notice must include the name, business address, and telephone number of the insurer and of the person to contact with questions about a claim.”


There is currently no legislative rule addressing this requirement, and the workplace notices required by § 23-2C-15(b) are not subject to review or approval by the OIC. However, OIC interprets this statute as requiring two basic pieces of information to be set forth in the notice.

First, the statute simply requires that the notice include the name, business address and telephone number of the employer’s workers’ compensation insurer. This requirement is straightforward and self-explanatory.

Second, the statute requires that the notice should contain information regarding the “person” an injured worker may contact with any questions he or she may have regarding a claim. OIC interprets this requirement broadly. The “person” identified in the notice may be 1) an employee of the injured worker’s employer – for example, a manager, human resources director or employee benefits coordinator; 2) an adjuster for the insurer; or 3) the insurer’s third-party claims administrator. However, the “person” identified: 1) should be readily available to the injured worker to personally assist the injured worker with the injured worker’s claim; and 2) should possess sufficient knowledge about the workers’ compensation claims process to adequately do so.

With regard to the physical composition of the notice, the statute provides no requirements with regard to the composition or size of the notice, or typeface used in the notice, and these determinations are left to the discretion of the insurer. It should be noted that the statute requires the notice to be posted in a conspicuous place upon the employer’s premises. Consistent with spirit of this directive, notices should be composed in a fashion that will provide workers with the required information in a legible format that can be easily seen and understood.

WORKERS' COMPENSATION FORMS
The following forms are approved for use in West Virginia workers’ compensation claims. Private carriers may modify these forms with regard to trade dress and carrier-specific Information (e.g., the name and mailing address of the private carrier or third party administrator), and may alter the forms to provide space for the entry of information on the form by the private carrier; HOWEVER, private carriers may NOT modify, add or subtract fields requesting information to be provided by injured workers without prior OIC approval. These forms have recently been prepared by the OIC as examples of approved forms for general use:
  • LinkIcon Application for 104 Weeks Dependents' Benefits [OIC-WC-202]
  • LinkIcon Application for Fatal Dependents' Benefits [OIC-WC-201]
  • LinkIcon Application to Reopen Partial Disability Claim
  • LinkIcon Carrier Request For Occupational Lung Center Examination
  • LinkIcon Employers' Report of Occupational Injury or Disease [OIC-WC-2]
  • LinkIcon Employee's & Physicians' Report of Occupational Hearing Loss [OIC-WC-1HL]
  • LinkIcon Employees' and Physicians' Report of Occupational Injury or Disease [OIC-WC-1]
  • LinkIcon Employees' Report of Occupational Pneumoconiosis [OIC-WC-1OP]
  • LinkIcon Employer's Report of Occupational Pneumoconiosis [OIC-WC-2OP]
  • LinkIcon Failure To Timely Act
  • LinkIcon Physician's Report of Occupational Pneumoconiosis [OIC-WC-30P] - Includes ILO Form
  • LinkIcon Request for Settlement Review
  • LinkIcon Termination of Coverage Form
Third Party Administrators' Forms
The following forms are currently in use by a third-party administrator of OIC-administered claims, and provide an example of additional forms which are approved for use in West Virginia:
  • LinkIcon Application for PTD Benefits
  • LinkIcon Controlled Substances Form
  • LinkIcon Attending Physician Benefits Form
  • LinkIcon Diagnosis Update
  • LinkIcon Low Back Examination
Notices to Dependents
The following Notices to Dependents Under W. Va. Code §23-4-10(f) are to be used by the WV Offices of the Insurance Commissioner, self-insured employers, private carriers and TPAs to inform dependents receiving 104-week awards that they may be eligible for benefits under W. Va. Code §23-4-15 and to explain how to apply for such benefits.  Please refer to Informational Letter No. 176 on the Insurance Commissioner's website at www.wvinsurance.gov for additional information regarding these notices.
  • LinkIcon Initial Notice Under WV Code §23-4-10(f) To Recipients Of 104-Week Award Paid In Monthly Payments
  • LinkIcon Notice Under WV Code §23-4-10(f) To Recipients Of 104-Week Award Paid In A Lump Sum
  • LinkIcon Second Notice Under WV Code §23-4-10(f) To Recipients Of 104-Week Award Paid In Monthly Payments
BROCHURE

This brochure is approved for use by the Offices of the Insurance Commissioner to meet the requirements in W. Va. Code §23-5-1a.

 - Workers' Compensation Claim Process for the Injured Worker

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