North Dakota Workforce Safety and Insurance Important Notice to Employees Poster Poster

1600 E Century Ave, Ste 1 - PO Box 5585 - Bismarck ND 58506-5585(701) 328-3800 1-800-777-5033 Hearing Impaired: 1-800-366-6888 Decision Review Office: (701) 328-9900 1-800-701-4932 Fraud & Safety HotLine: 1-800-243-3331
Filing a claim (3 methods):
Online:  www.WorkforceSafety.com  (Online Services Section),
24 hours/weekends/holidays
By hand:  Complete the First Report of Injury (FROI) Form and submit to WSI
Telephonically:  1-800-777-5033, 8 a.m. - 5 p.m. on business days
The information contained 
in this poster is effective 
August 1, 2013 and available 
online for printing at 
http://www.workforcesafety.
com/library/LibrarySearch
Results.asp.  
For a detailed explanation of  
the information contained in 
this poster, please contact 
WSI at the numbers listed 
below or visit our website at 
www.WorkforceSafety.com.
When You Are Injured On The Job:
Notify your employer immediately of the accident and your injury.  By law, you must give  written or oral 
notice to your employer within seven days of an accident or after the general nature of your injury 
becomes apparent.   If you fail to notify your employer, Workforce Safety & Insurance (WSI) may consider 
that failure when deciding whether your claim will be accepted.   NOTE: Even if you feel your injury is not 
serious enough to need medical treatment, it is important you report your accident to your employer so 
they are informed of the potential hazard.
Seek first aid or medical attention promptly after a workplace injury.   If your employer does not have a 
Designated Medical Provider (DMP), you may go to a doctor of your choice.   If your employer does 
have a DMP, you are required to see your employer’s DMP, UNLESS you informed your employer, in 
writing, of a different medical provider before any injury occurred.  In order to effectively select a DMP, 
your employer is required to give written notice of the identity and the terms of the preferred provider 
program:
  (1) To the employer’s employees when the employer makes an initial selection of 
       
 a preferred provider.
  (2) To the employer’s employees when the employer changes the selection of the 
       
 preferred provider.
  (3) To an employee at the time of hire.
  (4) To the employer’s employees at least annually after the initial notice.
An employer that has selected a preferred provider shall display notice of the identity of the preferred 
provider and the terms of the preferred provider program in a conspicuous manner at fixed worksites, 
and wherever feasible at mobile worksites, and in a sufficient number of places to reasonably inform 
employees of the identity of the preferred provider and the terms of the preferred provider program.  
Failure to give written notice, to properly post notice, or to reasonably inform employees of the terms of 
the preferred provider programs as required under this subsection invalidates the selection.
Contact your employer or WSI for more detailed information about this requirement.  Emergency 
medical treatment is exempt from the DMP requirement.  Inform the doctor that your injury is a workers’ 
compensation injury.  Also, inform the doctor of your work duties and ask if you can return to work within 
any work restrictions the doctor may impose.  Follow restrictions, both on and off the job. 
File a claim with WSI immediately after a work-related injury occurs (within 24 hours of occurrence).
Use one of three methods: 
                1) online at www.WorkforceSafety.com, available 24 hours/weekends/holidays 
       (follow online instructions); 
   2) by hand by completing the First Report of Injury (FROI) Form, or 
   3) telephonically by calling 1-800-777-5033, 8 a.m. - 5 p.m. on business days.
Whichever claim filing method is used, complete the FROI form with your employer, if possible.  Answer 
all questions fully and honestly on the form.  Be sure to have your employer complete the employer’s 
portion of the FROI form.  If you have received benefits for an injury and are now off work again for that 
same injury, you must reapply for benefits in writing.  Contact WSI and request a Worker’s Notice of 
Reapplication (C4) form.
WSI will inform you of your claim number, in writing, upon registering your claim.   
Be sure to always inform the pharmacy and medical provider of your claim number.
 
Keep in touch with your employer and provide them with periodic updates on your condition.
Notify WSI immediately: 
   1) when you perform any type of work activity, whether you receive pay for it or not; 
   2) if you change your address or telephone number; or 
   3) if you apply for either Social Security disability or retirement benefits or are found to be 
       eligible for these benefits.
Types of Benets
Available:
 Wage Replacement
 Medical Benefits
 Pharmacy Benefits
    WSI will pay for 
    prescriptions that are    
    part of the necessary    
    work-related medical 
    care when obtained
    at pharmacies and 
    medical facilities that    
    are contracted with    
    WSI’s prescription 
    benefit management 
    company.  WSI does 
    not reimburse for 
    prescriptions that are 
    paid out-of-pocket by 
    an injured worker.

 Reimbursement for
  
  Personal Expenses
 Return-to-Work             
    Services
 Death Benefits
Our/Your Designated Medical Provider (DMP) selection is:
Scan  here to
learn more on the types of benefits.
NOTICE
I M P O R T A N T
T
 O   W O R K E R S
    
November 2013
North  D akota  W orkforce
Safety  
& Insurance
WSI