Welcome to the Worker’s Compensation Page!

All who work for the City of Racine are covered by Worker’s Compensation if they sustain a work related injury. The City is self-insured for Worker’s Compensation. Employees who lose time from work because of occupational injury or disease will receive timely Worker’s Compensation payments from the City in accordance with Wisconsin State Statutes. All accidents involving personal injuries, however small, shall be reported immediately to your supervisor who shall notify the Human Resources Department. In addition, within 24 hours the appropriate injury report form must be completed and forwarded to Human Resources. This reporting requirement is done to meet State and Federal recording requirements, and for your protection. Injuries not reported within a specific period of time may not be compensable under the Worker’s Compensation Act. Contact your supervisor if you are unsure of how to complete the required report. Your supervisor will complete the form if you are medically unable.

1. One copy of the First Report of Injury Form must be sent to the Human Resources Department. A copy should also be retained in the employee’s department. The Human Resources Department will send a copy to the third part administrator and to the Department of Industry, Labor and Human Relations if required.

Employee’s First Report of Incident Form

Supervisor Review of Injury or Illness

Witness Statement

2. If the employee requires medical attention, the employee must submit to the medical provider City Form RWC-04, which authorizes treatment, release of medical records and provides for proper billing. This form must be signed by the employee and witnessed by a supervisor. If medical treatment is delayed beyond the day of injury, a copy of the RWC-04 must be sent to the Human Resources Department. 

Authorization for Treatment, Disclosure of Medical Records & Payment for Worker’s Compensation Injury Form

3. It is the supervisor’s responsibility to notify the Human Resources Department if an employee misses time off the job beyond the day of injury. Further, it is City policy to provide light duty whenever possible when it is consistent with medical restrictions. The Human Resources Department must be kept informed of light duty and notified when the employee returns to work.  

Below are local Urgent Care providers that can treat employees for injuries that occur while on duty;

    Concentra Urgent Care

Address: 1147 Warwick Way, Racine, WI 53406

Phone: 262-886-3997

  Aurora Occupational Medicine

Address: 8348 Washington Avenue, Mt. Pleasant, WI 53406

Phone: 262-884-4051

   Wheaton Restore Occupational Health

Address: 10180 Washington Avenue, Mt. Pleasant, WI 53177

Phone: 262-687-6150

Cities and Villages Mutual Insurance Company has a program that provides an incentive payment to you for the following medical services;

• Physical Therapy
• Diagnostic Testing (x-rays, MRI’s and CT Scans)
• Orthopedic Services

You will receive a non-taxable incentive payment if you choose to seek medical treatment at one of the participating providers that is listed in the “Worker’s Compensation Incentive Program Brochure” below. Participation in this incentive program is voluntary. 

Worker’s Compensation Incentive Program Brochure

The City of Racine is committed to complying with all the relevant and applicable provisions of the Americans with Disabilities Act (ADA) and State law. the City will make reasonable accommodations wherever necessary for all employees or applicants with disabilities, provided that the individual is otherwise qualified to safely perform the essential duties and assignments connected with the job and provided that any accommodations made do not impose an undue hardship on the City. 

For the full Reasonable Accommodation policy, please refer to page 10 of the City of Racine Employee Handbook. 

Procedure for Requesting an Accommodation:

An employee who believes that he or she needs a reasonable accommodation to perform an essential function of their job should make that request through their direct supervisor or the Human Resources Director.

When a request for accommodation is received by the supervisor or when it is apparent that a reasonable accommodation may enable a disabled individual to perform the essential functions of the position, the employee will be directed to submit a “Reasonable Accommodation Request Form” with appropriate supporting documentation to his or her direct supervisor and the Human Resources Director for consideration. 

Americans with Disabilities Act (ADA) Employee Accommodation Request Form

All requests for accommodation shall be responded to in a timely fashion, after the supervisor has engaged in the “interactive process” with the employee requesting the accommodation. 

Americans with Disabilities Act (ADA) Response to Accommodation Request Form

The City reviews all requests for accommodation on a case by case basis and may provide a reasonable accommodation that allows the qualified individual with a disability to achieve the same level of job performance as other similarly skilled employees. The City is not obligated to provide an accommodation that causes an undue hardship on the City.

All requests and documentation will be kept confidential and in a separate file.