Leg Injury

Reporting Procedures

EMPLOYEE IS INJURED

If Injury results in death or overnight hospital stay call IPEP immediately at 800-382-8837.

COMPLETE FORMS AND SUBMIT TO IPEP

1. FIRST REPORT OF INJURY (Completed by Employer)

2. SUPERVISOR'S INCIDENT REPORT (Completed by Employer)

3. MEDICAL AUTHORIZATION FORM (Completed by Employee)

[email protected]

fax 765-868-3310

IS TREATMENT REQUIRED?

YES

DIRECT EMPLOYEE TO DESIGNATED OCC HEALTH CLINIC OR ER

CONTACT IPEP FOR ANY REFERRALS

NO

CLAIM IS SET UP AS A RECORD ONLY WITH IPEP

CONTACT IPEP ASAP IF TREATMENT BECOMES NECESSARY

IPEP Reporting Procedures