For More Information

Veronika Quinn
Benefits Analyst
(781) 736-4471

Accident Form

Workers Compensation

Brandeis employees are covered by the laws of the Commonwealth of Massachusetts relating to Workers Compensation Insurance. The coverage provides a weekly cash benefit and payment for medical expenses relating to an accidental injury while at work for the university. Brandeis has elected to self-insure for workers compensation.

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Supervisor Responsibility

If an employee is injured, their supervisor needs to complete an accident report and send to Human Resources right away (attention: Veronika Quinn, Benefits Analyst).  The Commonwealth of Massachusetts, Department of Industrial Accidents, requires the Employer report the event of an injury within one week, involving 5 or more calendar days of total or partial incapacity from earning wages.

Injuries with no time lost, medical only, should also be reported to Human Resources, attention, Veronika Quinn, Benefits Analyst, (ext 64471, right away so that medical bills may be sent directly to the Self-Insurance Company, CCMSI, for payment.

Supervisor’s Report of Accident Forms are in every Department, however, please contact Veronika Quinn, Benefits Analyst to send a supply if you don’t have any.

Calculation Time and Payment

The First 5 days of time away from work due to the injury is paid through the employee’s sick time and is calculated as follows:

The employee is paid through Brandeis University for the day of the accident, i.e., 1/09/013. The next day is calculated as the first day out, 1/10/13 and the fifth day would be 1/14/13. The Department of Industrial Accidents counts 5 days, regardless of whether or not there are days off in between. Their theory is that the injured employee may have another job on their days off and therefore loses the capacity of earning money at their part-time job.

The Workers Compensation representative in the Human Resource department completes the Commonwealth of Massachusetts Department of Industrial Accidents Employer’s Notification of Injuries form from the supervisor’s First Report of Injury. Included in this report is: Name of injured employee, job title, address, phone number, social security number, date of birth, date of hire, hourly wage, piece or hourly worker, hours worked per day, days worked per week, average 52 week wage, date of injury, time of injury, source of injury, employer location code, to whom injury was reported and when, description of how injury occurred, injured body parts and whether or not employee has returned to work. All forms are sent to CCMSI, Self-Insurance Company for Brandeis University. If time lost involved, a copy is sent to Commonwealth of Massachusetts, Department of Industrial Accidents.

If employee is out of work beyond 5 days, a doctor’s note must be provided stating approximate time employee is restricted from work. These notes must be provided on a monthly basis. Human Resources will put the employee on unpaid leave of absence (effective the day after the fifth day) as the employee will be mailed weekly indemnity payments by CCMSI (self-insurer company) at 60% of their average 52 week, weekly wage. When an employee returns from Worker Compensation, Human Resources will end the Workers Compensation leave of absence.  The date of return to work is determined by the doctor’s note stating the date they can return to work with no restrictions (full clearance).

The Workers Comp representative contacts the Benefits Department when the employee is out longer than 5 days so that the benefit coverage will be billed directly to the employee.