Montana Required Postings and Forms
The adjusting of the claims in this state are handled by Intermountain Claims. Once a claim is reported to EMPLOYERS, the claim will be assigned to Intermountain Claims. The contact information for Intermountain Claims is:
P.O. Box 4546
Missoula, MT 59806
406-543-7195
Please print and post the following notices, both in English and Spanish, in a conspicuous location frequented by employees such as the break room, lunch room or time clock. If you have multiple business locations, be sure to post the notices at each location.
The following forms need to be completed and submitted to EMPLOYERS when a work-related injury occurs:
- First Report of Injury and Wage Statement Form
- Form ERD-991 First Report of Injury or Occupational Disease (FROI). (click link above) Employees must submit a written and signed First Report of Injury (FROI) within 12 months from the date of their accident or occupational disease. They can submit this form to you, EMPLOYERS or the Department of Labor and Industry. Upon receipt of your signed FROI, EMPLOYERS has 30 days to accept or deny your employee’s claim.
- Wage Statement (Included in Form ERD-991). This form enables us to calculate the correct compensation that may be owed to an injured employee. Please complete this form and submit it to EMPLOYERS within five days after your knowledge of any accident that has caused your employee to be disabled for more than three scheduled work days.
Please note the above two forms are combined. Make sure you follow the submission time requirements.
- First Fill Form. This form provides your employees with basic information about our Pharmacy Benefit Program, including such things as the phone number to call to locate a First Fill participating pharmacy. When your employee becomes injured, please print and complete this form and provide it to your injured employee. Your employee will need to provide this completed form along with the prescription for his/her work-related injury or occupational disease to the pharmacist. Using this form will help enable quick authorization for your employee’s initial medication and ensure that the initial prescription is provided at no cost to the injured employee.
- Accident Investigation Report. This basic accident form should be completed by the employee’s supervisor/manager as soon as possible after the accident. Please send the report to the following EMPLOYERS address as soon as it has been completed by the supervisor/manager: EMPLOYERS Claim Department, P.O. Box 14791, Lexington, KY 40512-4791. You should also keep a copy on file for your records.
More Montana Workers’ Comp Resources
- Off-Site Transitional Duty Program – Helping Your Injured Employees Get Back to Work. A successful transition back to work relies on the collaborative efforts of the manager/supervisor, the injured employee and their adjuster. As a manager/supervisor, learn what you can do to help facilitate a successful return to work.