XYZ Company
 Workers' Compensation
________ is a member of the New Hampshire Automobile Dealers Association Workers' Compensation Trust (NHADA WCT).
NHADA WCT participates in a formal workers' compensation managed care program with the Windham Group’s Work Injury Network.
WIN is a program designed to assist employees who have sustained a workplace injury/illness by making certain that all employees receive prompt and appropriate medical attention for these workplace injuries/illnesses. If you sustain a workplace injury/illness please follow these guidelines.
If you fail to follow these guidelines you may incur expenses that you will be responsible for.
All employees are required to report any workplace injury/illness immediately to their manager.
Injuries/Illness That Require Medical Treatment:
•	All employees are required to contact NHADA WCT Nurse Case Manager, Marta Silakka, at 800-852-3372 before you seek medical attention.
•	Ms. Silakka will assist you by referring you directly to an appropriate specialist within the Windham Group’s Work Injury Network.
Life Threatening/Emergency Injury/Illness:
•	In the case of a life-threatening emergency, immediately seek medical treatment at the nearest emergency room.
•	When you are able to do so, inform your manager and notify Marta Silakka, RN as soon as possible at 800-852-3372.
Please sign and date to acknowledge that you understand this policy.
Should you have any questions please feel free to contact _____________ at ______________.
Employee Name (please print)                                		Date: _____/____/_____

Employee Signature