Worker's Compensation Info



  • In an emergency, take your injured employee to the nearest emergency facility.
  • For all work-related injuries, provide the list of panel physicians to the injured employee.
Please refer to the Flow Chart and text below for specific directions. For your convenience, entire Worker's Compensation Injury Reporting Packet linked below, as well as single form access and explanation. Please phone HR at 724-850-2221 should you have any questions.
Have the injured employee complete the worker's comp injury reporting packet above and email the completed forms to the HR Office, [email protected] or [email protected]
Employee Acknowledgement of Rights
  • This form explains the employee’s rights under the Pennsylvania workers’ compensation law that must be signed by the employee at the time of injury.                                  
  • Send this copy to the HR Office along with the Injury Report Form.
  •  Medical Authorization Form
    •  This form authorizes Eastern Alliance to request medical records related to the injured employee's claim
  • Work Status Form and Modified Duty Notice
    •  Have the injured employee take these forms to his/her treating physician.
    Provide a signed copy of the form to the HR office.
Pharmacy Information
Should you require prescription medication due to your work related injury, please review the KeyScripts form below for instructions on activating a temporary KeyScripts Prescription Benefit Card. Please do not present your personal medical insurance card for any work related injury expenses.
Accident Investigation Form needs completed by Supervisor with the
injured employee to determine corrective actions to prevent future incidents.