Workers Comp / Insurance Forms

This area of the employee section deals with health and insurance-related issues.  For workers comp information, contact the Benefits Coordinator - Michelle Stewart: 

  • Phone: 423-753-1822
  • Fax number: 423-913-8304
  • After hours call 423-384-7034

If You're Injured on the Job

Injuries must be reported within 24 hours of the injury. The form to use for reporting injuries to employees of Washington County is: Tennessee Department of Labor Employer’s First Report of Injury 

Please ensure the first report form is completed.  The top sections of the form are pre-populated with the correct information.   The employee needs to complete the sections that are highlighted.  If the employee is unable to complete the form, the supervisor can complete the form.  It is very important that form is signed.

All injuries that occur at work must be reported regardless if the employee chooses to seek treatment or not.  

Employees reporting an injury must select a physician for treatment from the panel list.  Even if the employee is not seeking treatment for the injury, the employee must specify if they were seeking treatment which panel physician they would choose.  Please complete the highlighted for the sections.

Once completed, fax both forms to the HR/Benefits Coordinator at 423-923-8304 or scan and email to mstewart@washingtoncountytn.org.  If Michelle is out of the office, you will receive instructions on who is handling workers compensation claims while she is away.  Please be sure to follow the instructions that you will be provided.

If the employee needs medical attention, please provide the employee the Workers’ Compensation Claim Ticket.  This form provides the medical provider all the necessary information and provides the employee all the information and prescription billing information.  The employee does not take the first report form to the medical provider, only the claim ticket and the employee should keep the claim ticket, the provider should make a copy.