How to Submit a Workers’ Compensation Claim
To Report a Workers Compensation Claim please fill out the on-line form and call the ESD 112 Workers’ Compensation Department at 800-749-5861 or 360-750-7504.
What to do if an employee is injured at work
1. Inform the employee’s supervisor
If an employee is injured on the job or diagnosed with an occupational disease, the employee must inform his/her supervisor immediately.
2. Complete an employee incident report
Not all incidents become workers’ compensation claims, but all employee incidents need to be recorded to retain the facts of the injury and to gather information for loss prevention purposes. Complete the on-line Employee Incident Report form. Paper copies of the previous employee incident form will still be accepted.
3. If the employee requires medical attention
If medical attention is required contact ESD 112 Workers’ Compensation Claims Department at 1-800-749-5861 to report the incident. If medical care is provided you must obtain a claim number to submit a claim.
4. What the employee needs to tell the medical provider
Inform the medical provider that this is a work related incident and that the district is self-insured as a member of the Southwest Washington Workers’ Compensation Trust. A Provider’s Initial Report (PIR) should be completed at the medical provider’s office. Provide the medical provider with the assigned claim number. If a claim number has not been assigned, contact ESD 112 Workers’ Compensation Claims Department immediately. Instruct the medical provider to forward all claim information and authorization requests to:
ESD 112 Workers’ Compensation Claim Department
2500 NE 65th Avenue, Vancouver WA 98661-6812
Phone: 360-750-7504 | Fax: 360-750-9836
5. What to do after each medical provider visit
Contact ESD 112 Workers’ Compensation Claims Department following each visit to report medical and return to work status. Copies of all work status notes must be provided to both the employee’s supervisor and ESD 112 Workers’ Compensation Claims Department within 24 hours of receipt.
6. Expect a follow up phone call from ESD 112 Workers’ Compensation Claims staff
ESD 112 Workers’ Compensation Claims Department will investigate each claim within 24 hours of notification of an injury. A three point contact will be completed with:
- The injured employee
- The injured employee’s supervisor
- The attending medical provider
The purpose of these calls is to gather the legally mandated information to submit and process a workers’ compensation claim.