Kentucky

1. If you are a drug free workplace, send the injured work for post-accident drug testing per your drug free policy procedures.
2. Complete Form 1A-1, First Report of Injury or Illness providing details of the accident and injury.
3. Complete Form 106 Medical Waiver and Consent. This is a medical authorization form, enabling you or the Division of Workers’ Compensation to obtain medical information relative to your employee’s work related injury/illness. This form needs to be completed and signed by our employee then submitted to Benchmark Administrators.
4. Complete Form 113 Notice of Designated Physician. The injured worker may choose the physician (including chiropractors) who treats him/her as the "designated physician." This notice identifies the designated physician where the injured worker is receiving medical care. You will need to provide this form to Benchmark Administrators within 10 days from the start of treatment.
5. 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.
6. After each medical appointment, the injured worker must provide medical documentation signed by their physician documenting their ability to return to work or their disability from work. This information will need to be provided to Benchmark Administrators after each appointment.

Submit all correspondence and medical bills to:

Benchmark Administrators
P.O. Box 46350
Las Vegas, NV 89114
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.