Workers' Compensation Notice

Notice to Employees in Regard to Workers’ Compensation Insurance

  • Reference Rule 110.101


    (a) In addition to the posted notice required by subsection (e) of this section, covered and non-covered employers shall notify their employees of coverage status in writing. This additional notice:

    (1) shall be provided at the time an employee is hired, meaning when the employee is required by federal law to complete both a W-4 form and an I-9 form or when a break in service has occurred and the employee is required by federal law to
    complete a W-4 form on the first day the employee reports back to duty;

    (2) shall be provided at the time the employer notifies the insurance carrier that the employer is dropping coverage if there will be a period during which the employees will not be covered;

    (3) shall be provided at the time an employer obtains coverage, as necessary to allow the employee to elect to retain common law rights;

    (4) shall include the text required in the posted notice (see rule 110.101(e)(1), (e) (2), (e) (3) for appropriate language); and

    (5) if the employer is covered by workers' compensation insurance, or becomes covered, whether by commercial insurance or by becoming a certified self-insurer, shall include the following statement:

    NOTICE TO NEW EMPLOYEES

    "You may elect to retain your common law right of action if, no later than five days after you begin employment or within five days after receiving written notice from the employer that the employer has obtained coverage, you notify your employer in writing that you wish to retain your common law right to recover damages for personal injury. If you elect to retain your common law right of action, you cannot obtain workers' compensation income or medical benefits if you are injured.”