Employee FMLA FormFamily FMLA FormS & A authorization form and instructionsInsurance payment coupon for health and life insuranceHow to report an occupational injury/disease claim1.Report an accident that happens at work as soon as it happens2.If you think you injury or health condition is work related, tell that to the dispensary and make sure the doctor or nurse checks off the “Claimed occupational” on all dispensary forms.3.If you injured yourself at work be sure to describe the accident to the doctor.4.If you developed a condition over time due to the wear and tear on you body from your job juties, make sure to describe your job duties to your doctor so he or she understands how the physical requirements of your job caused you to develop the condition.5.If you are claiming a work-related injury, you must file a form 18 with the North Carolina Industrial Commission. Filing an incident report is not enough. 6.You must file an accident report (F159) within 30 days of the accident in the dispensary.7.When you are on workman’s comp you must pay your medical, dental and life insurance premiums. You can download the form for this on this page to the get coupons you need to send in your payments.Sickness and Accident BenefitsBenefits will be paid because of a disabling accident, sickness,or pregnancy while under the care of a doctor licensed to practice medicine. Benefits are payable from:1. The first day of disablility due to an accident or occupantional illness, or2. The eighth day of disability due to a non occupational sickness or pregnancy, or3. The first day of hospital confinement prior to the eighth day, or4. The first day on which an employee undergoes a surgical procedure for which a benefit is payable under the program, provided the employee has not worked the day of the surgery.If you have surgery on your off day, you are entitled to A & S benefits for that day and any additional days that a doctorlicensed to practice medicine provides coverage.The forms and instructions can be downloaded from this page.Pension and Insurance Damita Rucker-Ash Office: 910-822-1906910-822-1751 Secure HIPPA fax:910-822-5189 Union Cell 910-723-3721Health and Wellness InformationImpact provides access to professional counseling, guidance, support and resources available to you and your dependents for personal and or work related issues.Wilmington Treatment Centeris a private alcohol and drug treatment center for chemically dependent individuals seeking recovery. Phone NumbersBlue Cross Blue Shield 1-800-792-7484United Healthcare 1-800-259-1605Delta Dental 1-800-524-0149Eye Med 1-800-334-7591Medco 1-866-544-3698Minnesota Life 1-800-660-2584JP Morgan 401K 1-800-345-2345Savings Bonds 1-800-426-9314Impact 1-800-227-6007A&S Benefits 1-866-574-4252VEBA medical and Dental 1-866-694-6477
Medco mail order formfor prescriptions
Eye Med Vision CarePatient Services 1-866-723-0513 Access Plan H
Employee FMLA Form
Family FMLA Form
S & A authorization form and
instructions
Insurance payment coupon for
health and life insurance
How to report an occupational
injury/disease claim
1.Report an accident that happens at work
as soon as it happens
2.If you think you injury or health condition
is work related, tell that to the dispensary
and make sure the doctor or nurse checks
off the “Claimed occupational” on all
dispensary forms.
3.If you injured yourself at work be sure to
describe the accident to the doctor.
4.If you developed a condition over time due
to the wear and tear on you body from your
job juties, make sure to describe your job
duties to your doctor so he or she understands
how the physical requirements of your job
caused you to develop the condition.
5.If you are claiming a work-related injury, you
must file a form 18 with the North Carolina
Industrial Commission. Filing an incident
report is not enough.
6.You must file an accident report (F159) within
30 days of the accident in the dispensary.
7.When you are on workman’s comp you must
pay your medical, dental and life insurance
premiums. You can download the form for this
on this page to the get coupons you need to
send in your payments.
Sickness and Accident Benefits
Benefits will be paid because of a disabling accident, sickness,
or pregnancy while under the care of a doctor licensed to
practice medicine. Benefits are payable from:
1. The first day of disablility due to an accident or
occupantional illness, or
2. The eighth day of disability due to a non occupational
sickness or pregnancy, or
3. The first day of hospital confinement prior to the eighth
day, or
4. The first day on which an employee undergoes a
surgical procedure for which a benefit is payable under
the program, provided the employee has not worked the
day of the surgery.
If you have surgery on your off day, you are entitled to A & S
benefits for that day and any additional days that a doctor
licensed to practice medicine provides coverage.
The forms and instructions can be downloaded from this page.
Pension and Insurance
Damita Rucker-Ash
Office:
910-822-1906
910-822-1751
Secure HIPPA fax:
910-822-5189
Union Cell 910-723-3721
Health and Wellness Information
Impact provides access to professional counseling,
guidance, support and resources available to you
and your dependents for personal and or work
related issues.
Wilmington Treatment Center
is a private alcohol and drug treatment center for
chemically dependent individuals seeking recovery.
Phone Numbers
Blue Cross Blue Shield 1-800-792-7484
United Healthcare
1-800-259-1605
Delta Dental
1-800-524-0149
Eye Med
1-800-334-7591
Medco
1-866-544-3698
Minnesota Life
1-800-660-2584
JP Morgan 401K
1-800-345-2345
Savings Bonds
1-800-426-9314
Impact
1-800-227-6007
A&S Benefits
1-866-574-4252
VEBA medical
and Dental
1-866-694-6477
Medco mail order form
for prescriptions
Eye Med Vision Care
Patient Services 1-866-723-0513 Access Plan H
Provider Listing
