Revised 10/26/2015
WORKER’S COMPENSATION COMMISSION (WCC)
Guam Department of Labor
P.O. Box 9970 • Tamuning, Guam 96931
Email Address: wcc@dol.guam.gov
Tel: (671) 300-4571/77 • Fax: (671) 475-6811
EMPLOYEE (PUBLIC)
WHAT TO DO IN CASE OF A WORK INJURY
1. REPORT the accident immediately to your employer regardless of whether or not
you need medical treatment. Request form GWC-201 (Notice of Employee’s
Injury/Illness or Death) from your employer. Complete form and provide copy to
your employer. Make sure you retain an acknowledged copy of your report. You
MUST report your injuries IMMEDIATELY.
2. If you need immediate medical treatment, obtain form GWC-101A/B (Authorization
for Medical Examination and/or Medical Treatment) from your employer. Your
employer will issue only the first (initial) authorization. All other (subsequent)
authorizations (including prescriptions) shall be issued by WCC. Unless it is an
emergency situation, this form is to accompany you to Guam Memorial Hospital
Authority (GMHA). DO NOT USE YOUR PERSONAL HEALTH INSURANCE and DO NOT
PAY FOR ANY MEDICAL SERVICES YOU RECEIVED.
GOVGUAM EMPLOYEES: are to be sent to the GMHA for the initial medical treatment
pursuant to 17 GAR Div. 2 Chap. 10 §10107(b) unless otherwise authorized by
WCC. Any referrals after this initial treatment must be authorized by WCC.
PLEASE ADVISE EMPLOYEE TO GO DIRECTLY TO WCC AFTER CHECKING OUT OF
GMH.
IMPORTANT: If you obtain medical treatment without
first requesting from your supervisor/employer or WCC,
you may not be reimbursed for any out-of-pocket
medical expenses, unless you have been refused such
authorization by your employer. 22 GCA §9108
You SHOULD always obtain or request for authorization before receiving any medical
treatment unless your injuries are such that emergency care is required.
WARNING: Misrepresentation of facts in order to obtain or evade liability of
worker’s compensation benefits shall be guilty of a misdemeanor.
WORKER'S COMPENSATION COMMISSION
Department of Labor * Government of Guam
P. O. Box 9970 Tamuning, Guam 96931
Tel: (671) 300-4571/77 Fax: 671-475-6811
WCC File #:
INSTRUCTIONS: This form may be used by the Employee to file a NOTICE of an injury, illness or in the case of death, by Employee's representative. No
benefits need be paid without this notice. Notice shall be given to the Commissioner and to the Employer by delivery or to the last known place of business.
22 GCA 9113. PLEASE PRINT OR TYPE.
** THIS IS NOT A CLAIM **
1. Name of injured Employee, DOB, & SSN: - -
2. Name of Employer & EIN:
3. Employee's address & telephone no: ( )
4. Employer's address:
5. Date & time of alleged injury/illness: 6. Did employee stop work?
If so, date stopped:
7. Employee's occupation:
8. Name of supervisor at time of injury:
9. Place where injury occurred:
10. Is another person not of your employment the cause of the
accident?
[ ] YES [ ] NO
11. Will you file suit against the other person?
[ ] YES [ ] NO
12. DESCRIBE IN FULL HOW THE ACCIDENT OCCURRED: Relate the events which resulted in the injury/illness. Tell what the
Employee was doing at the time of the accident. Tell what happened and how it happened. Name any object or substance involved and tell
how they were involved. Give full details on all factors which led or contributed to the accident. Use additional sheets if required and attach
to this report.
13. Effects of the injury (Indicate parts of body affected and how affected).
22 GCA §9132 “Any person who willfully makes any false or misleading statement or representation for the purpose of obtaining any benefit or
payment under this Title, or for the purpose of evading liability for any benefit or payment under this Title, shall be guilty of a misdemeanor.”
14. Name & signature of person completing this notice:
15. Date of this notice:
FOR STATISTICAL PURPOSES ONLY
Please choose ONE ETHNICITY: Please choose ONE CITIZENSHIP:
Yapese Marshallese American
Chuukese Palauan African American
Kosraean Guamanian Japanese
Pohnpeian Filipino Korean
Chinese Other (specify):
United States
Permanent Resident Alien
Other (specify):
Form GWC-201: NOTICE of EMPLOYEE'S INJURY/ILLNESS or DEATH (Revised 3/2014)
WORKER'S COMPENSATION COMMISSION
Department of Labor * Government of Guam * P.O. Box 9970 Tamuning, Guam 96931
Tel: (671) 300-4571/77 * Fax: (671) 475-6811
WCC File#
INSTRUCTIONS: This side of the form should be completed in full. It authorizes a physician (duly qualified physicians include surgeons,
osteopathic acupuncturists within the scope of their practice as defined by law) to examine and/or treat the employee for the injuries arising out of
such accidental occupational injury, illness, or disease covered by the Guam Worker's Compensation Law. PLEASE TYPE OR PRINT LEGIBLY.
1. Name of Authorized Physician:
2. Name of Medical Facility:
3. Physician's Address:
4. Medical Facility's Address:
5. Name of Injured Employee , DoB, & SSN:
6. Occupation:
7. Date of Injury:
8. Description of Injury:
9. YOU ARE AUTHORIZED TO PROVIDE MEDICAL SERVICES TO THE EMPLOYEE AS FOLLOWS: (Please check one)
A) If you believe the condition is related to the injury, furnish office and/or hospital treatment as necessary for the effects of
the injury.
B) If there is doubt as to whether the condition is related to the injury, you are authorized to examine the employee, using
indicated non-surgical diagnostic studies, and should promptly advise those listed in Item 14 whether you believe the
disability is due to the alleged injury. Pending further advice, you may provide such necessary conservative treatment.
C) Other
YOU ARE REQUESTED TO SUBMIT A WRITTEN REPORT OF FIRST TREATMENT WITHIN 20 DAYS TO THE COMMISSIONER AT THE ADDRESS
INDICATED ITEM 13 BELOW. (See back of this form for instructions as to the medical report and the submission of your charges). Reports are
requisite if services are to be paid.
22 GCA §9132 “Any person who willfully makes any false or misleading statement or representation for the purpose of obtaining any benefit or
payment under this Title, or for the purpose of evading liability for any benefit or payment under this Title, shall be guilty of a misdemeanor.”
11. Name and Address of Employer:
13. Send your REPORT to:
14. Name & address of Insurance Carrier to whom COPY of your report and BILL are to be sent:
WORKER'S COMPENSATION COMMISSION
P.O. Box 9970
Tamuning, Guam 96931
FOR STATISTICAL PURPOSES ONLY:
Employee’s ethnicity (please choose one):
Employee’s citizenship (please choose one):
Yapese Pohnpeian American
Korean
Chuukese Marshalls Pacific Islander
Chinese
Kosraean Palauan Filipino
Japanese
Other (specify):
U.S.
Permanent Alien Resident
Other (specify):
FORM GWC-101a: AUTHORIZATION for MEDICAL EXAMINATION and/or TREATMENT (Revised 3/2014)
ATTENDING PHYSICIAN'S REPORT OF INJURY AND TREATMENT
INSTRUCTIONS TO PHYSICIAN: This initial report should be completed and mailed within 20 days, the original to the
Commissioner (see item 13 for address), with a copy to the Company in item 14. Subsequent reports should be made regularly on
Form GWC-204 or in narrative form while employee is in your care. Please read Item 9 on the front of this form. PLEASE TYPE
OR PRINT LEGIBLY.
15. What history of injury or disease did Employee give to you?
16. Is there any history or evidence of PRE-EXISTING injury, disease, or physical impairment? [ ] NO [ ] YES (Describe):
17. What are your findings?
18. What is your diagnosis?
19. Do you believe the condition found was CAUSED or AGGRAVATED by the employment activity described? [ ] YES [ ] NO
(Please explain if there is doubt):
20. Did injury require hospitalization? [ ]YES [ ]NO
Hospital:
Admission date:
Discharge date:
21. Is additional hospitalization required? [ ] YES [ ] NO
22. Surgery (If any, please describe):
Date performed:
23. Other types of treatments:
24. What PERMANENT DEFECTS do you anticipate?
25. Date of first examination:
26. Dates of treatments:
27. Date of discharge:
28. Period of TEMPORARY DISABILITY
(Indicate if unknown):
Partial Disability: From To
Total Disability: From To
29. Date Employee was able to resume work:
LIGHT WORK [ ]
REGULAR WORK [ ]
30. If Employee is able to resume work, date when advised:
31. If Employee is able to resume only light work, indicate extent of PHYSICAL LIMITATIONS and type of work he could reasonably perform with
limitations:
32. General remarks and RECOMMENDATIONS for future care, if indicated:
33. Do you SPECIALIZE? [ ] NO [ ] YES (Please specify):
22 GCA §9132 “Any person who willfully makes any false or misleading statement or representation for the purpose of obtaining any benefit or
payment under this Title, or for the purpose of evading liability for any benefit or payment under this Title, shall be guilty of a misdemeanor.”
34. Name & Signature of Physician:
35. Address:
36. Date of report:
37. MEDICAL BILL (Charges for your services may be presented in the space below or on your billhead).
Date/Period of treatment(s)
Service/Supplies
(MUST be itemized)
Quantity
Unit
Price
Amount
Form GWC-101b Revised (3/2014)