Page 92 - An Indispensible Resource for Being a Credible Activist

HR TOOLS

SAMPLE WC CARD

Workers’ Comp (WC) Policy Number

A sentence that says “Send all bills to: Workers’ Comp (Carrier Company Name), Phone,
Address, and Contact info for billing inquires at the WC Insurance Carrier

Your Company’s FEIN (Federal Employer Identification Number) and UI (Unemployment
Insurance) Reg. Number

A sentence that says: “I am an injured employee of (Company). Provide address, phone
number, and an e-mail contact if possible.”

SAMPLE LETTER TO MEDICAL PROVIDERS WHO
ERRONEOUSLY BILL EMPLOYEES OR COMPANY
FOR WORKERS’ COMPENSATION BILLS

On letterhead, via postal mail, fax, or e-mail

Date
To Whom It May Concern:

The bill we are sending to you was erroneously sent to either an employee or this work-
place. This bill relates to a workers’ compensation injury; therefore, only the workers’
compensation (WC) carrier listed below should be billed by any medical provider related
to this case.
All of (Company)’s employees present a card to any WC medical provider, which includes
all of the necessary WC billing information needed by the medical provider.
In case you no longer have that information, I have provided it for you below:

Name and full address and contact info for (Company)’s WC Insurance carrier:
(Company)’s WC Policy Number:
(Company)’s FEIN (Federal Employer Identification Number):

Our UI (Unemployment Insurance) Reg. Number:
The State in which this employee works:

For any billing inquiries related to this or any other workplace injury related to
(Company), please call: __________________________ (phone number for Company’s
WC carrier)

CHAPTER 5 • Legal Issues Concerning Compens ation, Insurance, Leave 75