Workers’ Compensation

Eastern Alliance Insurance Group
PO Box 83777
Lancaster, PA 17608-3777
(717) 396-7095 OR (888) 654-7100

The Pennsylvania Bureau of Workers’ Compensation requires that the following
information be provided to every employee at the time of hire and immediately after the
injury, or as soon thereafter as possible under the circumstances of the injury. If the
employee’s injuries are so severe that emergency care is required, the information shall
be given as soon after the occurrence of the injury as is practicable. The information must
be printed on paper no smaller than 8 1/2 × 11 inches and in font no smaller than 11
point.
Workers’ Compensation Information
(1) The workers’ compensation law provides wage loss and medical benefits to
employees who cannot work, or who need medical care, because of a work-related injury.
(2) Benefits are required to be paid by your employer when self-insured, or through
insurance provided by your employer. Your employer is required to post the name of
the company responsible for paying workers’ compensation benefits at its primary place
of business and at its sites of employment in a prominent and easily accessible
place, including, without limitation, areas used for the treatment of injured employees or
for the administration of first aid.
(3) You should report immediately any injury or work-related illness to your employer.
(4) Your benefits could be delayed or denied if you do not notify your employer
immediately.
(5) If your claim is denied by your employer, you have the right to request a hearing
before a workers’ compensation judge.
(6) The Bureau of Workers’ Compensation cannot provide legal advice. However, you
may contact the Bureau of Workers’ Compensation for additional general information at:
Bureau of Workers’ Compensation
1171 South Cameron Street, Room 103
Harrisburg, Pennsylvania 17104-2501
Telephone number within Pennsylvania: (800) 482-2383
Telephone number outside of this Commonwealth: (717) 772-4447
TTY (800) 362-4228 (for hearing and speech impaired only)
www.state.pa.us, PA Keyword: workers comp.

PA POLICY NOTICE

Instructions for claims:

In the event of an incident or injury involving a district employee, follow the steps below:

The employee’s direct supervisor, building administrator, or school nurse should be immediately notified.
For emergency care send the employee to the nearest emergency room.
Complete the Eastern Alliance Claim Reporting Worksheet. Questions with one * MUST be completed (even if the employee chooses to not seek immediate treatment).
Have the employee read and sign the “Employee Acknowledgement of Rights and Duties” form and check “after an injury” box (even if the employee chooses to not seek immediate treatment). Make a copy for the employee.
Provide the injured worker with the temporary KeyScripts card (attached below).
Send the following documents to Jamie Sortman at the District Service Center immediately:
1. Eastern Alliance Claim Reporting Worksheet (questions marked with one * MUST be completed)
2. Signed Employee Acknowledgement of Rights and Duties
3. Any additional information, such as witness information, pictures, etc.