Sentry Insurance Group North Point Drive, Stevens Point, WI WC (Ed. 7/06)
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1 Sentry Insurance Group WC (Ed. 7/06)
2 (Este aviso debe ser puesto en un lugar accesible al empleado todo el tiempo.) AVISO OFICIAL Esta companfa opera bajo las Leyes de Compensacibn de Trabajadores de Georgia LOS TRABAJADORES DEBEN REPORTAR TODOS LOS ACCIDENTES INMEDIATAMENTE AL EMPLEADOR Y AVISAR AL EMPLEADOR PERSONALMENTE, UN AGENTE, PREPRESENTANTE, PATRON, SUPERVISOR O CAPATAZ. Si un trabajador es lesionado en el trabajo el empleador debe pagar gastos medicos y rehabilitation dentro de los limites de la ley. En algunos casos el empleador tambien pagara una parte de los salarios perdidos de los empleados. Lesiones de trabajo y enfermedades ocupacionales deben ser reportados por escrito cuando sea posible. El trabajador puede perder el derecho a recibir compensacion si un accidente no es reportado dentro de 30 dias (referenda O.C.G.A ). El empleador ofrecera sin costo alguno, si es pedido, un formulario para reportar accidentes y tambien debe suministrar, sin costo alguno, information acerca de compensacion de trabajadores. El empleador tambien debe suministrar al empleado, cuando sea pedido, copias de formularios de la Junta archivados con el empleador pertenecientes a reclamos de los empleados. Un trabajador lesionado en el trabajo debe seleccionar un doctor de la lista abajo. El panel rmnimo debe consistir de por lo menos seis medicos, incluyendo un cirujano ortopedico con no mas de dos medicos de clinicas industrials (referenda O.C.G.A ). Adem2s, este panel debe incluir un medico minoritario, cuando sea posible (vea la regia 201 de definition de medicos minoritarios.) La Junta puede otorgar excepciones al tamano requerido del panel donde se demuestre que mas de cuatro medicos no son razonablemente accesibles. Un tambio de un doctor a otro en la lista se puede hacer fin permiso. Cambios adicionales requieren el permiso del empleador o de la Junta Estatal de Compensacion de Trabajadores. Junta Estatal de Compensacion de Trabajadores 270 Peachtree Street, N.W. Atlanta, Georgia nombre /direccibn /telbfono nombre /direccibn /telefono nombre /direccibn /telefono nombre /direccibn /telbfono nombre /direccibn /telefono nombre /direccibn /telefono (Medicos adicionales pueden ser agregados en una hoja separada.) La compania de seguro que provee cobertura para esta Empresa bajo la ley de Compensacibn de Trabajadores es: Sentry Insurance Group Nombre direccion telefono SI USTED TIENE PREGUNTAS LLAME AL (404) o o VISITA SITIO WEB: HACER FALSOS TESTIMONtOS VOIUNTARIAMENTE CON EL PROPOSITO DE OBTENER O NEGAR BENEFtClOS ES UNCRIMEN SUJETO A PENALIDADES OE HASTA POR VIOLAClON ( O.C.GA Y ) WC-P1 (7/2006) WC (Ed )
3 WC (Ed )
4 WC (Ed )
5 (This notice must be posted in a conspicuous place readily accessible to the employee at all times.) OFFICIAL NOTICE This business operates under the Georgia Workers Compensation Law. WORKERS MUST REPORT ALL ACCIDENTS IMMEDIATELY TO THE EMPLOYER BY ADVISING THE EMPLOYER PERSONALLY, AN AGENT, REPRESENTATIVE, BOSS, SUPERVISOR, OR FOREMAN. If a worker is injured at work, the employer shall pay medical and rehabilitation expenses within the limits of the law. In some cases the employer will also pay a part of the worker's lost wages. Work injuries and occupational diseases should be reported in writing whenever possible. The worker may lose the right to receive compensation if an accident is not reported within 30 days (see O.C.G.A ). The employer will supply free of charge, upon request, a form for reporting accidents and will also furnish, free of charge, information about workers' compensation. The employer will also furnish to the employee, upon request, copies of board forms on file with the employer pertaining to an employee's claim. State Board of Workers' Compensation 270 Peachtree Street, N.W. Atlanta, Georgia or Your employer has enrolled with the certified Workers' Compensation Managed Care Organization (WC/MCO) listed below to provide all the necessary medical treatment for workers' compensation injuries. The effective date is shown below. If you had an injury prior to the effective date listed below you may continue to receive treatment from your current non-participating authorized physician until you elect to utilize the services of the WC/MCO. Each employee will be furnished with a publication which explains in detail how to access the services of the WC/MCO and provides a complete list of the medical providers available. In addition, each employee will be given a wallet-sized card which contains information on the services of the WC/MCO including a 24-hour toll-free phone number with recorded messages of information on how to utilize these services. NAME OF WC/MCO MAILING ADDRESS GEOGRAPHICAL SERVICE AREA NAME OF CONTACT PERSON PHONE NUMBER OF CONTACT PERSON ADDRESS OF CONTACT PERSON 24-HOUR TOLL-FREE PHONE NUMBER EFFECTIVE DATE OF WC/MCO The insurance company providing coverage for this business under the Workers' Compensation Law is: address Sentry Insurance Group Name phone IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS COMPENSATION AT OR OR VISIT Willfully making a false statement for the purpose of obtaining or denying benefits is a crime subject to penalties of up to $10, per violation (O.C.GA and ). WC-P3 (7/2006) WC (Ed )
6 (Este aviso debe ser puesto en un lugar accesible al empleado todo el tiempo.) AVISO OFICIAL Esta compama opera bajo las Leyes de Compensacion de Trabajadores de Georgia LOS TRABAJADORES DEBEN REPORTAR TODOS LOS ACCIDENTES INMEDIATAMENTE AL EMPLEADOR Y AVISARLE AL EMPLEADOR PERSONALMENTE, UN AGENTE, REPRESENTANTE, FEJE O CAPATAZ. Si un trabajador se lesiona en el trabajo, el empleador debe pagar los gastos medicos y de rehabilitation dentro de los limites de la ley. En algunos casos el empleador tambien pagara una parte de los ingresos perdidos. Lesiones de trabajo y de enfermedades ocupacionales deben ser reportado por escrito cuando sea posible. El trabajador puede perder los derechos de recibir compensacion si un accidente no es reportado dentro de 30 dias (referenda O.C.G.A ). El empleador ofrecers una planilla sin costo alguno cuando sea pedida para reportar accidentes y tambten sin costo alguno, puede suministrar informacidn acerca de compensacion de trabajadores. El empleador tambien suministrar^, si es pedido, al empleado, copias de planillas de la junta archivadas con el empleador pertenecientes a reclamos de los empleados. Junta Estatal de Compensacion de Trabajadores 270 Peachtree Street, N.W. Atlanta, Georgia o Su empleador esta matriculado con la organizacidn administrativa de cuidados de compensacion de trabajadores (WC/MCO) inscrito abajo, para proveer todos los tratamientos medicos necesarios en lesiones de compensacidn de Trabajadores. El dia efectivo aparece debajo. Si usted a tenido una lesion antes de la fecha efectiva inscrito abajo, usted puede continuar recibiendo tratamiento por su actual medico no-participante hasta que usted elija utilizar los servicios de WC/MCO. Cada empleado se le proveera una publication la cual explica en detalles como adquirir los servicios de la (WC/MCO) y se le proveera con una lista completa de los medicos proveedores disponibles. Y adem^s, cada empleado recibird una tarjeta tarnaho billetera que contiene information de los servicios de la WC/MCO incluyendo un numero disponible las 24 horas con mensaje grabados con informaci6n de como utilizar los servicios. NOMBRE DE WC/MCO DIRECCION AREA DE SERVICIO GEOGRAFICO NOMBRE DE PERSONA DE CONTACTO NUMERO DE TELEFONO DE PERSONA DE CONTACTO DIRECCION DE PERSONA DE CONTACTO NUMERO DE TELEFONO DE 24 HORAS FECHA EFECTIVA DE WC/MCO La compama de seguro que provee cobertura para esta Empresa bajo la Ley de Compensacion de Trabajadores es: Sentry Insurance Group Nombre Direccion Telefono SI USTED TIENE PREGUNTAS LLAME AL (404) o o VISITA SITIO WEB: HACER FALSOS TESTIMONIOS VOLUNTARIAMENTE CON EL PROP0SFTO OE OBTENER O NEGAR BENEFICIOS ES UN CRIMEN SUJETO A PENALIDAOES DE HASTA POR ViOLACIpN (O.C.G- A Y ) WC-P3 (7/2006) WC (Ed )
Sentry Insurance Group 1800 North Point Drive, Stevens Point, WI
Sentry Insurance Group 1800 North Point Drive, Stevens Point, WI 54481 1-800-739-3344 WC-80-10-0001 (Ed. 7/06) 10-06 Sentry Insurance Group 1800 North Point Drive, Stevens Point, WI 54481 1-800-739-3344
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