Maxcis, Incorporated

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MAXCIS

nTelephone Reporting Checklist

Maxcis, Inc. offers members several different options of claims reporting.  You may either call in your claim, fax (616.949.9250), or submit your claim online. 

 

Please use the Telephone Reporting Checklist (MIOSHA 301), when you call an injury in.  We encourage you to use our 800 number (1.800.930.7272) if you are not in the Grand Rapids Area.

 

*NOTE:  If you do not have a customized (employer specific) reporting checklist, you may contact our office. 

 

Please click here to submit your claim online.

 

 

nSupervisor’s Accident Investigation Report

This form is to be completed by the injured employee’s immediate supervisor.  If the employee did not seek medical treatment, a telephone reporting checklist does not need to be completed.  However, we do recommend that the supervisor’s report be placed in the employee’s personnel file in case medical treatment is needed at a later date.

 

nOrder for Medical Treatment

The injured employee is to take this form with him/her to the hospital/doctor for initial treatment. 

 

nWage Information Worksheet

This form is completed by the employer for any employee who misses more than seven calendar days from work.  This is used to compute the injured employee’s average weekly wage.  Benefits are calculated by using the highest 39 weeks of the last 52 weeks prior to the date of injury.  If the injured employee has worked less than 52 weeks, include all wages.

 

nPhysical Job Analysis

This form is to be completed by the injured employee’s supervisor.  An accurate job description is needed to determine if a return to regular work is possible or whether a return to work with accommodations is appropriate based on the physical requirements of the job. 

 

nMileage Log

This form can be given to injured employee’s requesting reimbursement for mileage.

 

nMIOSHA Forms (300, 300A, 301)

For more information in regards to MIOSHA recordkeeping guidelines, click here.

 

 

 

 

 

 

 

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