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Sample Language for Workers' Compensation

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Reviewed Date: January 03, 2017

Original Author: 
Stokes, Richard
Date of Material: 
Aug 30, 2012

Insurance--Workers compensation

Sample Language for Workers' Compensation

MTAS was asked to provide sample language for workers' compensation.

Knowledgebase-Sample Language for Workers' CompensationFrom: Stokes, Richard L
Sent: Thursday, August 30, 2012 11:10 AM
Subject: Worker's Comp sample language

Here is the sample language from our model.


An employee of the city/town of ____________ who suffers injury or illness as a result of a work related accident or condition shall receive compensation during the period of illness or injury by the State Compensation Insurance Fund in accordance with the Tennessee Worker’s Compensation Act. Worker’s compensation pays an employee 66.67% of their weekly salary once the employee has been disabled for more than seven (7) days. Compensation will be made as of the eighth day of disability due to an occupational injury. Employees shall receive their normal rate of pay less the workers compensation benefits. Such employee shall disclose to the Accounting Administrator and/or the Human Resources Department the amount of all worker’s compensation benefit payments received. Such pay by the City shall cease after three (3) months unless extended by the City Commission by resolution. If the employee is disabled for fourteen (14) days or more, workers compensation will pay the employee retroactively from the first full day of absence from work up to the return date to work. Employees receiving worker’s compensation payments may not supplement their pay with accrued leave to received wages in excess of 100% of their average annual salary.

Employees shall report any injury or illness incurred in the course of their employment, however minor, to their Supervisor or Department Head. Failure to make such a report may disqualify the employee from receiving Workers Compensation benefit and receiving any injury leave. The employment of an injured employee, who is unable to return after a period of three (3) months, may be reassessed by the (manager/administrator/ mayor/ governing body/ department head/ supervisor), at which time a ruling will be made.

I hope this information is helpful. Feel free to contact me if you have questions or I can be of any further assistance.

Richard L. Stokes, IPMA-CP, PHR
Office Manager/Human Resources Consultant
Executive Director - TN Chapter IPMA-HR
The University of Tennessee
Municipal Technical Advisory Service
226 Capitol Blvd. Bldg., Suite 606
Nashville, TN 37219
615/532-6827 (office)
615/532-4963 (fax)


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