Fillable Printable Workers' Compensation Notice - Indiana

Workers' Compensation Notice - Indiana

Indiana Worker's Compensation Board 04/21/05

WORKER'S COMPENSATION NOTICE

Your employer is required to provide for payment of benefits under the Worker's Compensation

Act of the State of Indiana.

Any employee who is injured while at work should report the injury immediately to their

supervisor, employer, or designated representative.

The worker's compensation insurance carrier or the administrator for

________________________________________ is: ______________________________________

(name of company) (name of insurance carrier or administrator)

__________________________________________________________________________

(name of carrier/administrator)

_________________________________________________________________________

(mailing address)

_________________________________________________________________________

(city, state, zip)

_________________________________________________________________

(telephone numbe r )

________________________________________________________________________

(contact person)

For more information about rights or procedures under the Indiana Worker's Compensation

system, call or write:

Worker's Compensation Board of Indiana

Ombudsman Division

402 W. Washington St., Rm W196

Indianapolis, IN 46204

(317) 232-3808

1-800-824-2667