Letter Templates for 12 Month Injury Leave Provisions

The following are sample letters that are typically used to administer the injury leave program. The letter templates may be saved to a file and customized for use for a specific claim or for an individual agency's needs. Please note that particular forms must often accompany the letters.

• Notification of Incident Only Claim: sent to employees who report incident only claims.
• Notification of Medical Only Claim: sent to employees who report medical only claims and miss no time from work.
• Notice for Absences of Less than Eight Days Beyond Date of Injury: sent to employees who are absent for less than eight days beyond the date of injury and incur medical expenses.
• Notice of Pending Workers' Compensation Decision/Windfall: sent to all employees who are absent for any time beyond the date of injury pending a decision from Inservco Insurance Services, Inc.
• Notice of Injury Leave Benefits/Leave Election: sent to employees who are absent for any time beyond seven days, after the claim is accepted.
• Notice of Injury Leave Without Pay: sent to employees who are absent for any time beyond the date of injury, after the claim has been accepted, but the employee has no accrued leave available or is a temporary employee with no leave accrual.
• Notice of Denial: sent to employees whose claims are denied.
• Notice of Recurrence: sent to all employees who are absent for any time beyond the date of recurrence pending a decision from Inservco Insurance Services, Inc.
• Notice of Depletion of Paid Injury Leave and Begin of Injury Leave Without Pay: sent as a courtesy to employees who initially elect to use paid injury leave and before returning to work, exhaust accrued leave.
• Notice to Return to Modified Duties: sent to employees to notify them that they have been released to modified work duties.
• Notice to Return to Work: sent to employees to notify them that they have been released to return to work.
• Notice of Termination of Benefits Due to Work-Related Injury: sent to employees to notify them that commonwealth benefits will be terminated after one year of absence due to the injury. It should be sent at least six weeks in advance of the expiration of leave with benefits.
• Notice of End of Three-Year Eligibility Period: sent to employees to notify them that injury leave will end. It should be sent at least 90 days in advance of the expiration of the three year eligibility period.
• Notice of Supplemental Agreement Signature Request Letter: sent to employees who have not signed the supplemental agreement when requested by the claims adjuster.