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Direct Deposit (Enrollment/ Change)

 
Employment
Changes

 
Work Related
Injury (Worker' s Comp)


 
To View and Print Forms
These forms are in the Adobe Acrobat (pdf) format.

In order to view or print the forms on this page, you must first have the Acrobat Reader installed on your machine. (We recommend version 6.0).

Should you need the reader, we have provided a link below to obtain the free program directly from the Adobe website.

INSTALL ADOBE ACROBAT

Work Related Injury (Worker's Comp) Forms -

County Department Heads

First Report of Injury Form
The First Report of Injury form should be completed and sent to the County Council office any time an employee sustains a work related injury, regardless of whether he/she seeks medical attention.

First Fill Program Pharmacy Card
If your employee is seeking medical attention, you should also fill out the First Fill Program pharmacy card and give to the employee. Use the injured employee's Social Security Number (written without dashes), and date of injury (written MMDDYY), for the ID. If the injured employee is prescribed medication for the injury, the completed form should be presented to a participating pharmacy along with the prescription. A maximum 14 day supply of medication(s) can be dispensed with this card. A permanent RX card will be mailed for the remaining or future fill of the medication(s). We have been advised that most major pharmacies including CVS, Rite Aid and Walgreens accept this program, however, smaller, independent pharmacies may not, so please make sure the employee is aware of this.

In the event your employee needs medical attention, you should also fill out the two-part Medical Authorization form with St. Mary's Occu-Med locations. Those forms are available in the County Council Office. The white copy of that form goes with the employee and the yellow copy should be sent to the County Council office.

If you have any questions, please don't hesitate to call Teri Lukeman, County Council Executive Assistant, at 812-435-5790 or email her at TLukeman@vanderburghgov.org.

You must have Adobe Acrobat Reader to use these forms which are in PDF format. If needed, you can use the link to to left to install Adobe.




Any comments or questions, email a contact.


 
     
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