Purpose of Form:
Injured employees must choose whether or not they will utilize accrued sick leave and any annual leave before receiving workers’ compensation income benefits.
The form must be received by SORM not later than the 5th calendar day after the first full day of lost time has occurred. If not received by that date, the employee will be paid under Election II – to use no accrued leave time. This election cannot be modified once implemented.
The claims coordinator and injured employee.
|Instructions:1. The Claims Coordinator will enter employee’s name, social security number, agency and claimant’s date of injury in the spaces provided. 2. The Claims Coordinator will explain to the employee the differences in the election options so that the employee can make an informed decision. After the employee makes the decision and signs the form, the form cannot be altered after the employee’s 8th day of disability. The reason for this is that it will affect how the benefits are paid and could result in an overpayment that the employee could possibly have to pay back to SORM or might result in an underpayment of benefits owed.|
Choose one: 1A, 1B, or 1C
|This option uses all accrued sick leave prior to receiving workers compensation benefits if owed. Three options of Election 1 are presented. The employee must choose one of the options.Election 1A – When the employee loses time from work due to the compensable injury or illness, the employee chooses to use all accrued sick and annual leave until it is exhausted, before receiving any workers’ compensation benefits. This means the employee will stay on the payroll until his/her sick and authorized annual leave is exhausted. This also means that if the claimant returns to work and then has additional days of disability, all additional sick and vacation leave accrued will be exhausted before receiving any additional workers compensation benefits.This also means that if the employee is out for an extended period for a serious illness and then returns to work, then there will be no sick or annual leave to use in case additional medical treatments are required.
Election 1B – This election states that the employee chooses to use all of his/her accrued sick and a portion of annual leave. The employee chooses how much annual leave he/she wants to use and the employee will stay on the payroll for as long as his/her sick and annual leave will cover. This also means that if the claimant returns to work and then has additional days of disability, all additional sick leave accrued and balance of authorized annual leave if any will be exhausted before receiving any additional workers compensation benefits.
Election 1C – This election states that the employee chooses to use all of his/her accrued sick leave and NONE of his/her accrued annual leave. This means the employee will stay on the payroll until his/her sick leave is exhausted. This also means that if the claimant returns to work and then has additional days of disability, all additional sick leave accrued will be exhausted before receiving any additional workers compensation benefits.
Choose Election 2
|This election states that when the employee loses time from work, he/she elects to use none of the accrued sick leave and noneof the accrued annual leave. This means the employee will be automatically placed into a leave with out pay status when he/she loses time from work. The first 7 days of disability is called the 7 day waiting period. Workers compensation income benefits, if owed, will not start until the 8th day of disability. If the employee returns to work and then has additional days of disability, the employee will return to leave without pay status. The waiting period will be paid after the employee has been unable to work for a total of 14 days.This is also the default election. If the SORM 80 is not received within 5 days after the first day of disability, this is the option that will be used. If the form is received later than the 5th day, the form will not be accepted. The employee will have to stay with Election 2 throughout the life of the claim. There will be no exceptions.
|3. If the employee elects any of the Option 1 choices, the claims coordinator must enter the number of sick leave hours and annual leave hours available in the spaces provided. The form will be rejected if the hours are not filled in.|
4. The claims coordinator will Fax a copy of the original to the State Office of Risk Management.
5. The claims coordinator will retain the original in the agency files.
NOTE: The claims coordinator must notify SORM via the SORM-90 within 2 calendar days of the expiration of the elected leave. This will ensure that benefits are paid timely.