"Employee Safe Working Practices Agreement Template - Gas Electric Company" - Florida

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EMPLOYEE SAFE WORKING PRACTICES AGREEMENT
Giles Electric Company, Inc.
1700 South Segrave Street
South Daytona, Florida 32119
As a condition of employment, I, __________________________________________
(please print name)
do hereby agree to comply with the following safe working practices:
1) I agree to follow established departmental safety procedures.
2) I agree to report any work related accident, or injury to my supervisor as soon
as it occurs, but no later than the end of my duty shift.
3) If I need treatment for a work related injury, I agree to:
A) Notify my EMPLOYER of the need for treatment.
B) Only go to an EMPLOYER directed physician(s) for necessary
treatment.
C) On the initial visit, hand carry a Medical Authorization For Treatment
form to the authorized treating facility.
D) Notify my EMPLOYER when referred for any specialist treatment and
only go to an EMPLOYER directed specialist.
I understand that failure on my part, to follow the above procedures, could result in
disciplinary action, not to exclude termination!
I also understand that according to Section 440.09 (4) of the Florida Workers’
Compensation Law, my compensation benefits could be reduced for any injury which
occurs because of a failure to follow established safety procedures.
____________________________________
_________________
Employee Signature
Date
____________________________________
Witness
EMPLOYEE SAFE WORKING PRACTICES AGREEMENT
Giles Electric Company, Inc.
1700 South Segrave Street
South Daytona, Florida 32119
As a condition of employment, I, __________________________________________
(please print name)
do hereby agree to comply with the following safe working practices:
1) I agree to follow established departmental safety procedures.
2) I agree to report any work related accident, or injury to my supervisor as soon
as it occurs, but no later than the end of my duty shift.
3) If I need treatment for a work related injury, I agree to:
A) Notify my EMPLOYER of the need for treatment.
B) Only go to an EMPLOYER directed physician(s) for necessary
treatment.
C) On the initial visit, hand carry a Medical Authorization For Treatment
form to the authorized treating facility.
D) Notify my EMPLOYER when referred for any specialist treatment and
only go to an EMPLOYER directed specialist.
I understand that failure on my part, to follow the above procedures, could result in
disciplinary action, not to exclude termination!
I also understand that according to Section 440.09 (4) of the Florida Workers’
Compensation Law, my compensation benefits could be reduced for any injury which
occurs because of a failure to follow established safety procedures.
____________________________________
_________________
Employee Signature
Date
____________________________________
Witness