WORKERS COMPENSATION

Welcome Aboard! Associates are to report all work-related incidents on the same day or within 24-hours of the
occurrence. Work related incidents are injuries, illnesses, and vehicle accidents that occur within the scope of
employment.
Claims are reported through a single point of contact* WC Claims number is 888-900-4276 option 3, 1, 1
Note: *Ohio, North Dakota, Washington, Wyoming, and Puerto Rico have different reporting

requirements. Please dial 888-900-4276, options, 3, 1, 2 for proper direction. Additional information
can be found on www.asmconnects.scom
Medical referrals to screened providers for proper medical treatment
Immediate medical treatment for an associate injured on the job
Faster communication with supervisors regarding work-status and any restrictions in an effort to get associates
safely back to work
So that youre prepared in the event of a work related incident, weve created wallet-cards which include the necessary
information and the simple steps to follow to report a work related incident. Print this letter, cut along the perforated lines
and then follow the directions below. If you live in OH, ND, WA, WY or Puerto Rico, scroll down until you find the
appropriate states reporting procedures and wallet card. Its that easy! Dont delay! If you are a Supervisor there is a
Supervisors WC instructional wallet card with important process steps that you will take during an associate work related
incident. Workers Compensation procedures and wallet cards are located on ASM Connects. Click here
Next Steps
1. If you live in Ohio, North Dakota, Washington, Wyoming or Puerto Rico, scroll down to the appropriate state
procedures and wallet cards.
2. If you do not live in the states listed in the first step, print this page and cut out the ICE wallet card.
3. Write the name and number of your Supervisor and Human Resources contact on lines 1 and 2 on the back of the
card.
4. It is a best practice to write your own personal emergency contact name on line 3 and then enter this persons phone
number in your cell phone directory under the name ICE. ICE Universally means In Case of Emergency. All
emergency responders will look in your phone directory for ICE if you are unresponsive due to an injury or illness.
5. Place the Wallet Card in your wallet or a place that you can easily access it should you need it.
If you have questions, please contact your Supervisor or HR Manager.
Remember SAFETY is everyones responsibility! Locate expected safe work guidelines on ASM Connects on the Safety
Site, ask your supervisor, or contact the Safety Department at 888-900-4276 option 3, then 2. Never complete a task
that you know is unsafe.

Cut

Cut
Emergency Contact Information

In Case of Emergency

Name

How to Report a Work-Related

Incident

1:

IN AN EMERGENCY CALL 911

REPORT all work-related incidents and get a clinic referral from

the ASM WC Claims Dept. by calling

888-900-4276 option 3, 1, then 1

(**Different process for OH, ND, WY, WA and Puerto Rico)

FAX doctors note to WC Claim 858-431-1158 - SAME DAY

CONTACT supervisor to discuss plan for returning to work
GO to all follow-up doctors appointments

Cut

Fold

Supervisor

2:
3:

Phone

Human
Resource Contact
Personal
Emergency Contact

Workers Compensation Claims Contact:

(Phone) 888-900-4276 option 3, 1, then 1
(Fax) 858-431-1158 (Email)
workerscompensation.claims@asmnet.com

Cut

Work Injury Process Ohio

Ohio workers compensation is an exclusive state insurance fund program. Benefits are determined and payable
via the state for Ohio residents. For more information visit the state website at:
http://www.ohiobwc.com/Default.aspx

Cut

In Case of Emergency
How to Report a Work-Related Incident in

Ohio
IN AN EMERGENCY CALL 911

REPORT all work-related incidents and get a clinic referral

from the ASM WC Claims Dept. by calling
888-900-4276, select options 3, 1, and 2
FAX/Email doctors note to WC Claim 858-431-1158 or
workerscompensation.claims@asmnet.com SAME DAY

Workers Compensation Identification Card - Ohio

Manage Care Organization (MCO): Advocare, INC
Ph: 800-659-4025 Fax: 216-514-1227
Employer: Advantage Sales & Marketing Policy#: 013017610000
Ohio Bureau of Compensation website/phone www.ohiobwc.com
All medical treatment requires authorization
Fold

Cut

Emergency Contact Information

Name
1.
Supervisor
2.
Human Resource Contact

CONTACT supervisor to discuss plan for returning to work

GO to all follow-up doctors appointments

Cut

3.
Your Personal Emergency Contact

Cut

Phone

Work Injury Process North Dakota

North Dakota workers compensation is an exclusive state insurance fund program. Benefits are determined and payable
via the state Workforce Safety & Insurance program. For more information visit the state website at:
www.WorkforceSafety.com

Cut

Cut
Workers Compensation Identification Card
North Dakota

In Case of Emergency
How to Report a Work-Related Incident in

North Dakota
IN AN EMERGENCY CALL 911

REPORT all work-related incidents and get a clinic referral

from the ASM WC Claims Dept. by calling 888-900-4276, select
options 3, 1, and 2
FAX/Email doctors note to WC Claim 858-431-1158 or
workerscompensation.claims@asmnet.com SAME DAY
CONTACT supervisor to discuss plan for returning to work
GO to all follow-up doctors appointments

Cut

Fold

Employer: Advantage Sales & Marketing

North Dakota Workforce Safety and Insurance
website/phone www.workforcesafety.com 800-777-8033
Authorization is required for all medical treatment

Emergency Contact Information

Name
1.
Supervisor
2.
Human Resource Contact
3.
Your Personal Emergency Contact

Cut

Phone

Work Injury Process Washington

Washington workers compensation is an exclusive state insurance fund program. Benefits are determined and payable
via the state Department of Labor & Industries for Washington residents. For more information visit the state website
at: http://www.lni.wa.gov/

Cut

Cut

Workers Compensation Identification Card

Washington

In Case of Emergency
How to Report a Work-Related Incident in

Washington
IN AN EMERGENCY CALL 911

REPORT all work-related incidents and get a clinic referral

from the ASM WC Claims Dept. by calling 888-900-4276, select
options 3, 1, and 2
FAX/Email doctors note to WC Claim 858-431-1158 or
workerscompensation.claims@asmnet.com SAME DAY
CONTACT supervisor to discuss plan for returning to work
GO to all follow-up doctors appointments

Cut

Fold

Employer: Advantage Sales & Marketing

(UBI: 601980760)
Washington State Dept. of Labor and Industries
website/phone http://www.lni.wa.gov/ 1-800-547-8367
Authorization is required for all medical treatment

Emergency Contact Information

Name
1.
Supervisor
2.
Human Resource Contact
3.
Your Personal Emergency Contact

Cut

Phone

Work Injury Process Wyoming

Wyoming workers compensation is an exclusive state insurance fund program. Benefits are determined and payable by
the state for Wyoming residents. For more information, visit the state website at: http://doe.wyo.gov/Pages/default.aspx.

Workers Compensation Identification Card WY

In Case of Emergency
How to Report a Work-Related Incident in
IN AN EMERGENCY CALL 911

REPORT all work-related incidents and get a clinic referral

from the ASM WC Claims Dept. by calling 888-900-4276, select
options 3, 1, 2
FAX/Email doctors note to WC Claim 858-431-1158 or
workerscompensation.claims@asmnet.com SAME DAY
CONTACT supervisor to discuss plan for returning to work
GO to all follow-up doctors appointments

Cut / Fold

Wyoming

Employer: Advantage Sales & Marketing

Wyoming Dept. of Employment website:
http://doe.wyo.gov/Pages/default.aspx

Emergency Contact Information

Name
1.
Supervisor
2.
Human Resource Contact
3.
Your Personal Emergency Contact

Phone

CLAIM PROCESS
Puerto Rico
If incident occur during week
days on business hours
8:00 am 3:30 pm

INJURED EMPLOYEE

Report injury or disability to

Continental Claims Service,
Inc. (787) 764-2485 extension
249 CCS will provide you with
the form CSFE-373.
Go to the regional office or
the intermediate dispensary
closest to your home to get
treatment.

Injured employee will keep CCS

informed and updated regarding
treatments, appointments and
status.

Contact CCS Representative to

report the incident:
Brenda Daz (787) 430-3848
Ismael Roque Jr (787) 438-0340

Go to a hospital emergency room

to get treatment and informed that
this is a job related injury.
CCS will fill and provide by fax
or email the Form CFSE-373
to the injured employee

Will set up the workers comp

claim at Juris and provide the
Client and Sedgwick with the
claim number.

CCS will update the Juris

System regarding the
condition of the injured
employee

Intermediate Dispensary
Cayey
Coamo
Corozal
Fajardo
Guayama
Jayuya
Manat
Utuado
Yauco

(787) 738-6700
(787) 825-6520
(787) 859-0200
(787) 801-5959
(787) 864-0095
(787) 588-0335
(787) 854-2495
(787) 894-2685
(787) 267-1110

If incident occur after business

hours or during weekends and
holidays.

CCS will report directly to

ASM the status of the injured
employee.

Hospital Industrial

Contact CCS the next business

day to get form CSFE-373 and

go to the Regional Offices or

Intermediate Dispensary
closest to your home.
Injured employee will keep CCS
informed and updated regarding
treatments, appointments and
status.

Regional Offices
Aguadilla
Arecibo
Bayamn
Caguas
Carolina
Humacao
Mayagez
Ponce
San Juan

(787) 882-3230
(787) 878-5757
(787) 782-8250
(787) 653-4400
(787) 757-6850
(787) 852-1400
(787) 833-8700
(787) 848-4545
(787) 282-7400

Vieques

(787)741-5442

(787) 754-2525

The State Insurance Fund Corporation is a public entity created with the purpose of guaranteeing the
well-being of the Puerto Rican working class.
It is important that workers who suffer any injury, accident, or occupational illness diligently carry out
the requirements established by the Worker Accident Compensation System Act in order to speed
the processing of their claim, for their benefit and that of their families.

The person to whom the accident occurred must go to the regional office or the intermediate
dispensary closest to their home. They must fill out form CFSE-373, Report to Employer,
within 5 days of the accident or the date they have been diagnosed with an occupational
illness. At that time, they will be examined and will receive adequate medical treatment, if
their condition requires it.

PROCESO DE RECLAMACIN
Si el incidente ocurre durante lunes
a viernes en horario de
8:00 am 3:30 pm

LESIONADO

Reportar la lesin o incapacidad a

Continental Claims Service, Inc.
al (787) 764-2485 extensin 249
CCS le proveer con la Forma
CSFE-373

Ir a la Oficina Regional o
Dispensario Intermedio ms
cercano a su residencia para
recibir tratamiento

El lesionado mantendr a CCS

informado sobre su tratamiento,
citas y estatus de su caso.

Llamar a un representante
de CCS para reportar el
incidente: Brenda Daz (787)
430-3848
Ismael Roque Jr (787) 438-0340
Ir a la sala de emergencia ms
cercana para tratamiento e indicar
que la lesin es laboral.
CCS proveer al lesionado la
forma CFSE -373 por
facsmil o correo electrnico

CCS entrar la reclamacin

en el Sistema de Juris y le
proveer al Cliente y a
Sedgwick CMS con el nmero
de reclamacin

CCS mantendr la informacin

actualizada del empleado
lesionado en el sistema de Juris

Intermediate Dispensary
Cayey
Coamo
Corozal
Fajardo
Guayama
Jayuya
Manat
Utuado
Yauco
Vieques

(787) 738-6700
(787) 825-6520
(787) 859-0200
(787) 801-5959
(787) 864-0095
(787) 588-0335
(787) 854-2495
(787) 894-2685
(787) 267-1110
(787)741-5442

Si el incidente ocurre fuera de

horas
laborables,
fin
de
semana o das feriados

Contactar a CCS al prximo da

laborable al (787) 764-2485
extensin 249 para que se le
prepare y de la Forma CSFE-373 e
ir a la Oficina Regional o
Dispensario Intermedio del Fondo
del Seguro del Estado.
El lesionado mantendr a CCS
informado sobre su tratamiento,
citas y estatus de su caso.

CCS le reportara directamente

a ASM el status de la condicin
del empleado lesionado.

Hospital Industrial
(787) 754-2525

Oficinas Regionales
Aguadilla
Arecibo
Bayamn
Caguas
Carolina
Humacao
Mayagez
Ponce
San Juan

(787) 882-3230
(787) 878-5757
(787) 782-8250
(787) 653-4400
(787) 757-6850
(787) 852-1400
(787) 833-8700
(787) 848-4545
(787) 282-7400

La Corporacin del Fondo del Seguro del Estado es una entidad pblica creada con el propsito de
garantizar el bienestar de la clase trabajadora puertorriquea.
Es importante que los trabajadores que sufren alguna lesin, accidente o enfermedad ocupacional
cumplan diligentemente con los requisitos que establece la Ley de Compensaciones por Accidentes
en el Trabajo. De esta manera se agilizar el trmite de la reclamacin para su beneficio y el de su
familia.

La persona accidentada deber acudir a la Oficina Regional o Dispensario Intermedio ms

cercano a su residencia. Debe presentar en el formulario CFSE-373, Informe Patronal, en los
prximos cinco das a partir del accidente, o de haber sido diagnosticado con una enfermedad
ocupacional. Adems, ser evaluado y recibir tratamiento mdico adecuado, segn lo
requiera su condicin.