EROA - Integrated Claims Management

This information will be used by L&I to determine benefits payments (if applicable).

Select the type of pay this employee receives:
HourlyHourly - On Call StatusFlat RateCommissionPieceworkSalaryOther

If Flat Rate, Commission, or Piecework - please indicate the average monthly wage for 6 months prior to the date of injury.

If On Call - please indicate the average monthly wage for 6 months prior to the date of injury.

If other - please indicate type

Rate of Pay
.
per HourDayWeekMonthYear

Hours Worked per Day *

Days worked per Week *

What is the average monthly amount paid in bonuses or spiffs over the last 12 months?

Average Hours of Overtime worked per month *

Will you keep this employee on salary? (paying regular wages while off work)
YesNo

If you have paid regular salary what dates have been paid?

Were you contributing to this employee's (or family) health care benefits on the date of injury? *
YesNo

Amount paid for health care benefits including vision and dental?
Health care is paid per...

If percentage, average paid per month:

Time Missed from Work

Last Date Worked *

Do you know the Return to Work date?
YesNo

Return to Work Date *

If the Return to Work date is unknown, please list the anticipated return to work date. *

Is the worker currently working with restrictions or in a light duty job?
YesNoWorking regular duty

If no light duty is available contact ICM to learn about a return to work solution using Light Duty Pathway or visit lightdutypathway.com.

If you question the validity, please list any supporting information.

If you would like an electronic version of this form, complete your e-mail below.

Employer Report of Accident