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Indiana

When an employee is injured on the job, proceed with the following:

  1. Complete Form SF 34401 First Report of Injury providing the details of theaccident and injury.
  2. Provide Benchmark Administrators with payroll records documenting 52 weeks of the injured worker’s salary history. If 52 weeks are not available, provide payroll records for the time period the injured worker was employed.
  3. If you are a drug free work place, post-accident drug testing must be completed in accordance with your drug free work place policy procedure.
  4. Contact a preferred urgent care facility by telephone prior to sending the injured worker. Inform the urgent care that you have an injured worker coming and that Benchmark Administrators is the claims administrator.
  5. Advise the injured worker they must return to your office or job site after receiving medical care and provide the doctor’s signed return to work slip or documentation of medical disability.
  6. Please forward the return to work/disability slip from the doctor to Benchmark Administrators as soon as possible.
  7. If a worker is seriously injured and needs immediate care or is transported by ambulance, the employer should have a co-worker or supervisor go with the injured worker to assist the injured worker with any insurance related information that the medical provider may require.
  8. If there is a serious injury, notify Benchmark Administrators immediately by telephone, Injured Workers’ Hotline 1-800- 289-4502.

Required State Forms

Indiana - First Report of Injury

Additional Forms

Medical Providers

Concentra

FirstCare Walk-In Clinic

Indiana Immediate Care

Correspondence and Medical Billing:

Benchmark Administrators
P.O. Box 940097
Maitland, FL 32794
Telephone: (314) 558-1273
Toll Free: (800) 362-5198
Fax: (314) 230-7003

24-HOUR CLAIM REPORTING HOTLINE: 1-866-337-0891
Customer Service Representatives are on staff 24 hours per day to assist you with reporting a claim. Please have the injured worker’s information available as well as the accident description.