Seubert & Associates

Online Library

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Seubert Safe Workplace Program

• Complete Seubert Safe Workplace Program
• Employee's Acknowledgement of Physicians Panel
• PA-Approved Safety Committee Guidelines
  (link to webpage of the PA Dept. of Labor & Industry)
• Injured Employee Report
• Witness Incident Report
• Employer's Job Evaluation
• Physician's Evaluation
• Modified Duty Form

Worker’s Compensation

• Worker’s Compensation Claim Form
• Worker’s Compensation Employee Acknowledgement Form

Automobile Accidents

• Incident Report
• Auto Accident Reporting Guide

Bond Forms

• Bid Bond Request Form
  (To be used if a specific bid bond is required. If performance, payment and/or maintenance bonds are required, please provide a copy of the contract.)
• Bid Results Form
  (To be used if performance payment and/or maintenance bonds are required.)
• Contractor’s Questionnaire
• Personal Financial Statement
• Work in Progress Report

Employee Benefits

• Medicare Creditable Coverage Model Notice
• Medicare Creditable Coverage Reporting to CMS
• Sample COBRA Initial Rights Notice

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