If you’ve been injured at work, follow these steps to claim Workers’ Compensation (WC).

• Teacher should notify Principal of injury immediately following the injury if possible.

• It is the responsibility of Principal/Supervisor to ensure all WC forms are available to employees.

• The office gives Teacher these two forms:
  • “Workers’ Compensation Report of Injury” form (PGIN 7540-2401)
  • “Workers’ Compensation Attending Physician” form (PGIN 7540-2402)
• Forms can also be secured by contacting the Benefits Administration Office (BAO).

• Teacher fills out the Report of Injury Form the same day or the next day. If employee unable, it is responsibility of Principal/Supervisor to complete form.

• Teacher returns Report of Injury Form to Principal for a signature. KEEP A COPY!

• Principal signs form and returns to Teacher.

• Teacher sends this form to BAO in the Sasscer Building. If teacher unable, it is responsibility of Principal/Supervisor to send to BAO.

• Teacher takes WC Attending Physician form to the doctor for completion.

• Teacher promptly sends this form to BAO.

• BAO will process Report of Injury to the Third Party Administrator for Prince George’s County, which is Schaffer Companies, LTD. Address is 9475 Lottsford Road, Suite 220, Largo, MD 20774, Phone # 301-925-4024. Schaffer Companies, LTD will issue claim number. Medical Bills: All medical bills should be submitted to Schaffer Companies, LTD at above address.

• It is the responsibility of the Principal/Supervisor to submit the “Verification of Employee’s Loss of Time Due to Work Related Injury” (VLT) form (PGIN 7540-2407) to BAO on a weekly basis to maintain employee’s pay status. Fax verification form to 301-952-6976. *Please note: employee is not charged leave for date of injury.

• Employee cannot be reimbursed sick leave or pay until the case is approved, and the “Verification of Loss of Time Due to Work Related Injury” form and the “Workers’ Compensation Attending Physician” form are received in the BAO.

• Employees with last names beginning with A-K should call Diana Mullen-Fines at 301-952-6321.

• Employees with last names beginning with L-Z should call Brenda Flowers at 301-952-6316.