Workers' Compensation

Human Resources is strongly committed to supporting all staff members' success throughout every stage of your employment.

Your Employer provides comprehensive workers' compensation insurance at no cost to employees. This covers any injury or illness sustained in the course of employment that requires medical, surgical, or hospital treatment. Subject to applicable legal requirements, workers' compensation insurance provides benefits after a short waiting period or, if the employee is hospitalized, immediately. Workers' Compensation insurance coverage is provided for all actively working employees, including temporary employees.

REPORTING POLICY FOR WORKERS' COMP

For further information regarding the Workers' Compensation Reporting policy please click on the link below:

PROCEDURES WHEN AN EMPLOYEE IS INJURED AT WORK

IN THE EVENT OF A WORK-RELATED INJURY:

  1. The employee must immediately notify his/her supervisor/manager

  2. The employee or supervisor/manager must immediately notify Domino's Farms Security Department at 734.930.3174

  3. The employee or supervisor/manager must also immediately notify Gloria Jancar/HR at 734.930.4542 for authorization to seek treatment and to initiate a claim for workers' comp.

ACCIDENT FUND POLICY NUMBERS FOR WORKERS' COMP COVERAGE

(ALL STATES EXCEPT OHIO)


1. POLICY NUMBER ALL STATES EXCEPT CALIFORNIA AND OHIO: WCV 616 5191

  • Treatment form link, all states except California and Ohio:

WC AUTHORIZATION TO TREAT FORM, ALL STATES EXCEPT CALIFORNIA AND OHIO, CONCENTRA (DOWNLOAD FORM FIRST FOR USE AS A FILLABLE FORM)


2. POLICY NUMBER CALIFORNIA ONLY: WCV 6167119

  • Treatment form link, California only:

WC AUTHORIZATION TO TREAT FORM, CALIFORNIA ONLY, CONCENTRA (DOWNLOAD FORM FIRST FOR USE AS A FILLABLE FORM)


OHIO WORKERS' COMPENSATION POLICY, OHIO BUREAU OF WORKERS' COMPENSATION

POLICY NUMBER OHIO ONLY: 80028128

  • Treatment form link, Ohio only:

80028128 OHIO WORKERS' COMPENSATION BUREAU (OHIO ONLY)

(DOWNLOAD FORM FIRST FOR USE AS A FILLABLE FORM)

It is the responsibility of every employee at the time of incident to immediately report a work-related injury or illness, both to their supervisor/manager and to Human Resources.

IF A MICHIGAN EMPLOYEE REQUIRES MEDICAL CARE FOR ON THE JOB INJURIES


  1. If this is a life-threatening injury or illness, go immediately for treatment, then follow-up with your supervisor after care is received

  2. In the event of a work-related injury or illness, you must immediately report the information to your supervisor/manager and to the Domino's Farms Security Department 734.930.3174

  3. If this is a not an emergency situation, and medical care is required, the employee must obtain the appropriate Authorization for Examination or Treatment form from their supervisor/manager.

  4. Non-emergency treatment should be performed at a location noted below:

  5. Employee must provide a picture ID when arriving for treatment

  6. It is the employee's responsibility to keep both your supervisor/manager and the HR Generalist informed of any follow-up doctor appointments, physical therapy, hospitalizations, etc.

  7. DO NOT present your BCBSM or BCN health plan ID card at the time of service as the responsibility for payment of such claims belongs to AF Group

MICHIGAN IN-NETWORK TREATMENT LOCATIONS FOR WORKERS' COMP INJURIES

To view Michigan in-network Concentra locations for Workers' Comp medical treatment please click on the link below:

IF A VOLUNTEER IS INJURED:

In the event a volunteer is injured while working, they will need to file a claim under the General Liability Insurance for payment.

OUT-OF-STATE EMPLOYEE REQUIRING MEDICAL CARE FOR ON THE JOB INJURIES


  1. If this is a life-threatening injury or illness, go immediately for treatment, then follow-up with your supervisor after care is received

  2. In the event of a work-related injury or illness, you must immediately report the information to your supervisor/manager or to the HR Generalist at 734.930.4542

  3. If this is a not an emergency situation, and medical care is required, the employee must obtain the appropriate Concentra Employers Authorization for Examination or Treatment form from their supervisor/manager or call the HR Department at 734.930.4542.

  4. It is your responsibility to make sure that the document is completed and returned to the HR

  5. Non-emergency treatment should be performed at a Concentra location (locations available below)

  6. Employee must provide a picture ID when arriving at Concentra for treatment

  7. It is the employee's responsibility to keep both your supervisor/manager and the HR Generalist informed of any follow-up doctor appointments, physical therapy, hospital

  8. DO NOT present your BCBSM or BCN health plan ID card at the time of service as the responsibility for payment of such claims belongs to the Accident Fund Group

OUT-OF-MICHIGAN IN-NETWORK WORKERS' COMP MEDICAL TREATMENT LOCATIONS

To view any out-of-state Concentra locations please review the chart below.

*** In the chart below any location highlighted in blue is a clickable link, as long as you click the link in this page. If you click the arrow/box that appears in the top left corner when you hover over the chart, the chart will open in a new tab. The links will not be operable in that new tab.***

If you wish to search for approved locations other than those noted above, you can use the provider search tool located on the Accident Fund website by clicking on the following link:

CONTACTS

Becky Zmuda, HR Director

734.930.3196

rzmuda@avemariafoundation.org OR

rzmuda@dominosfarms.com


Workers' Comp Claims:

Gloria Jancar, HR Generalist

734.930.4542

gjancar@avemariafoundation.org OR

gjancar@dominosfarms.com


COMPANY

AF GROUP

(ACCIDENT FUND)*

*Contact HR to file a claim.


WEBSITE

www.accidentfund.com


Locate a Provider for Medical Services (if chart above does not include your state):

http://www.accidentfund.com/about-afgroup/productsservices/accident-fund-ppo-provider-search/